A client who has been taking clozapine reports experiencing a sore throat and has a temperature of 101.9° F (38.8° C). Which action should the nurse take?
Encourage Increase Intake of oral fluids.
Obtain a specimen for a complete blood count.
Complete an Abnormal Involuntary Movement Scale (AIMS).
Administer a PRN dose of acetaminophen.
The Correct Answer is B
Choice A rationale: Encouraging an increase in oral fluids is a general intervention but may not address the specific concern related to a sore throat and elevated temperature.
Clozapine requires monitoring for potential agranulocytosis, and an infection should be ruled out with a complete blood count (CBC).
Choice B rationale: Obtaining a specimen for a complete blood count (CBC) is crucial to assess for clozapine-induced agranulocytosis, a potentially life-threatening side effect. A sore throat and fever are red flags for possible infection.
Choice C rationale: Completing an Abnormal Involuntary Movement Scale (AIMS) is not relevant to the current situation. A sore throat and fever require immediate attention to rule out infection.
Choice D rationale: Administering a PRN dose of acetaminophen may help reduce fever, but the priority is to investigate the potential cause of the symptoms. Obtaining a CBC is essential.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: "If your partner is abusing you, I need to ask these questions" may be too direct and could potentially make the client feel pressured or uncomfortable. The nurse should emphasize the routine nature of the screening.
Choice B rationale: "The healthcare provider needs to know if you are experiencing any domestic abuse" is correct but may sound directive. Emphasizing the routine nature of the screening helps to normalize the process.
Choice C rationale: "All clients are screened for domestic abuse because it is common in our society" is the best choice. It normalizes the screening process, reducing stigma and encouraging disclosure.
Choice D rationale: "State law mandates that I ask if you are a victim of domestic violence" may make the client feel compelled to answer due to legal reasons, potentially affecting the validity of the response. Emphasizing routine screening is a more patient centered approach.
Correct Answer is D
Explanation
A. An overdose of cocaine can be lethal:
While this statement is accurate, it focuses on extreme outcomes rather than addressing the student's belief in their ability to control cocaine use. It may not encourage the student to reconsider their stance on trying the drug.
B. Addiction affects all aspects of one's life and one's family:
This response provides important information about the long-term consequences of addiction but does not directly counter the student's claim about their ability to control initial use. It may not be as impactful in the immediate context.
C. Denial of an addiction problem is often the first response to the behavior:
This response assumes the student is already using substances or experiencing addiction. It does not directly address the student's specific belief in their ability to control their actions after trying cocaine.
D. Mind-altering drugs take away one's ability to make good decisions:
This response is most appropriate because it directly challenges the student's confidence in their ability to control their behavior. It provides a logical explanation of why experimenting with cocaine is inherently risky, as it impairs judgment and decision-making, making it harder to "stop" as they claim
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