A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms of schizophrenia? (Select all that apply.).

The correct answer is Choice D, sore throat.

Choice A rationale: Random blood glucose 130 mg/dL is not a priority finding for the nurse to report to the provider. This level is slightly above the normal range of 70 to 110 mg/dL, but it is not indicative of a serious condition such as diabetes mellitus or hyperglycemia. Clozapine can cause hyperglycemia in some patients, but this is usually a chronic effect that develops over months or years of treatment. Therefore, a single random blood glucose measurement of 130 mg/dL is not a cause for immediate concern or intervention. The nurse should monitor the client’s blood glucose levels regularly and educate the client on the signs and symptoms of hyperglycemia, such as increased thirst, urination, hunger, and fatigue. The nurse should also encourage the client to maintain a healthy diet and exercise regimen to prevent or manage hyperglycemia.

Choice B rationale: Nausea is not a priority finding for the nurse to report to the provider. Nausea is a common side effect of clozapine that usually occurs during the initial phase of treatment or after a dose increase. It is usually mild and transient and can be managed by taking the medication with food or water, using antiemetics, or reducing the dose if necessary. Nausea does not indicate a serious or life-threatening adverse reaction to clozapine, unless it is accompanied by other symptoms such as vomiting, abdominal pain, jaundice, or fever. The nurse should assess the client’s nausea and provide supportive care and education on how to cope with it.

Choice C rationale: Heart rate 104/min is not a priority finding for the nurse to report to the provider. This level is slightly above the normal range of 60 to 100 beats per minute, but it is not indicative of a serious condition such as tachycardia or cardiac arrhythmia. Clozapine can cause orthostatic hypotension, bradycardia, syncope, and cardiac arrest in some patients, but these are rare and serious adverse effects that require immediate medical attention. Therefore, a single heart rate measurement of 104/min is not a cause for immediate concern or intervention. The nurse should monitor the client’s vital signs regularly and educate the client on the signs and symptoms of orthostatic hypotension, such as dizziness, lightheadedness, or fainting when changing positions. The nurse should also advise the client to rise slowly from a lying or sitting position, avoid alcohol and other substances that can lower blood pressure, and drink plenty of fluids to prevent dehydration.

Choice D rationale: Sore throat is a priority finding for the nurse to report to the provider. Sore throat is a sign of infection, inflammation, or irritation of the throat, which can be caused by various factors such as viruses, bacteria, allergens, or irritants. However, in a client who is taking clozapine, sore throat can also indicate a serious and potentially fatal adverse effect of the medication: severe neutropenia. Neutropenia is a condition in which the number of neutrophils, a type of white blood cell that fights infection, is abnormally low. This increases the risk of developing serious and life-threatening infections, especially in the mouth, throat, and respiratory tract. Clozapine can cause neutropenia in some patients, especially during the first 18 weeks of treatment, and it is the most common reason for discontinuing the medication. Therefore, any client who is taking clozapine and develops a sore throat should be evaluated by the provider as soon as possible to rule out neutropenia and initiate appropriate treatment if needed. The nurse should also educate the client on the importance of regular blood tests to monitor the absolute neutrophil count (ANC) and the signs and symptoms of infection, such as fever, chills, weakness, or sore throat. The nurse should also instruct the client to avoid contact with people who are sick, practice good hygiene, and report any signs of infection immediately.

Choice A rationale:

The statement "I don't feel anything but numbness anymore" is indicative of anhedonia, which is a core symptom of clinical depression. Anhedonia is the inability to experience pleasure or interest in previously enjoyed activities. Reporting this statement to the provider is important as it suggests a significant emotional disturbance.

Choice B rationale:

While the statement "It'll be a long time before I'm happy again" does indicate a sense of hopelessness or prolonged sadness, it is not as specific to clinical depression as the presence of anhedonia. Clinical depression involves a range of symptoms, and the absence of pleasure or emotions (anhedonia) is a more concerning sign.

Choice C rationale:

Feeling angry at the world is a common emotional response to grief and loss and is not a direct indication of clinical depression. It is important to consider the context of grief when assessing client statements.

Choice D rationale:

Expressing reliance on family support is a healthy coping mechanism in response to grief and loss. It does not necessarily indicate clinical depression but rather a natural response to seeking support during a difficult time.