A nurse is caring for a client who is taking clozapine. For which of the following findings should the nurse withhold the medication?

The client has gained 1.4 kg (3 lb) in the past month.

The client reports a sore throat.

The client reports being constipated for 2 days.

The client reports feeling dizzy when getting out of bed.

Answer and Explanation

The Correct Answer is B

A) The client has gained 1.4 kg (3 lb) in the past month: Weight gain can be a side effect of clozapine, but a 3-pound gain over the course of a month is not an immediate concern. The nurse should continue to monitor the client's weight, but this alone is not a reason to withhold clozapine.

B) The client reports a sore throat: A sore throat could be a sign of a serious side effect of clozapine—agranulocytosis, a condition in which the body has a dangerously low white blood cell count, increasing the risk of infection. The nurse should withhold the medication and notify the healthcare provider immediately if the client reports a sore throat, as this is a potential early sign of agranulocytosis. A complete blood count (CBC) should be checked before continuing the medication.

C) The client reports being constipated for 2 days: Constipation is a common side effect of clozapine due to its anticholinergic properties. While the nurse should address constipation and encourage interventions like increased fluid intake or stool softeners, it is not a reason to withhold clozapine unless the constipation becomes severe or leads to other complications like bowel obstruction.

D) The client reports feeling dizzy when getting out of bed: Dizziness, particularly upon standing (orthostatic hypotension), is a common side effect of clozapine. The nurse should assess the severity of the dizziness and encourage the client to rise slowly from a sitting or lying position, but dizziness alone is not a reason to withhold the medication. However, if the dizziness is severe or persists, the nurse should notify the healthcare provider.

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Correct Answer is D

Explanation

A) Administer PRN medication for agitation: Administering PRN medication may be necessary if the client’s agitation becomes unmanageable, but it is important to first attempt non-pharmacological interventions, such as reducing stimuli, before resorting to medication. This approach helps in managing the client's agitation in a more holistic manner and avoids over-reliance on medication.

B) Request a prescription for physical restraints: Restraints should be considered a last resort and only after less restrictive interventions, like reducing stimuli or verbal de-escalation techniques, have been attempted. Restraints can escalate aggression and increase the risk of harm, so they should not be the first intervention in managing agitation.

C) Place the client in seclusion: Seclusion should only be used as a last resort when other methods have failed, and the client poses a risk to themselves or others. It is a restrictive intervention that can have negative psychological effects, so it is better to try less intrusive measures first, such as reducing environmental stimuli.

D) Attempt to reduce environmental stimuli: Reducing environmental stimuli is a non-invasive, first-line intervention for managing agitation. It helps decrease overwhelming sensory input and can calm the client down. This approach involves creating a quieter, more controlled environment, which can assist in de-escalating the situation before more drastic measures are needed.

A. I have kids at home, sometimes think t hear them too B. The children may be gone when you're done with therapy, would you like to join the others in the day room? C. Do you know the names of the children? D. That'd be quite odd; this nursing units just for adults.

Correct Answer is C

Explanation

A) I have kids at home, sometimes think I hear them too: This response, though seemingly empathetic, minimizes the client's experience and might make them feel misunderstood. It also brings the nurse's personal experiences into the conversation, which can detract from focusing on the client's current reality and distress.
B) The children may be gone when you're done with therapy, would you like to join the others in the day room?: While this response attempts to redirect the client, it doesn't directly address the client's perception of the children in the room. It can come off as dismissive, as it doesn’t validate the client’s experience or engage with the underlying issue of their perception.
C) Do you know the names of the children?: This response is therapeutic because it gently engages the client in exploring their perception and reality. Asking the client about the children allows them to feel heard and gives the nurse insight into the client’s mental state, possibly indicating a symptom such as hallucinations or delusions, which the nurse can address appropriately.
D) That'd be quite odd; this nursing unit's just for adults: While the nurse is stating a fact, this response can sound dismissive or dismissive of the client’s experience. Instead of validating the client’s perception or gently exploring it, it focuses on the oddity of the situation, potentially making the client feel alienated or disregarded.

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A nurse is caring for a client who is taking clozapine. For which of the following findings should the nurse withhold the medication?

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