A nurse is caring for several clients who have mental health disorders at an assisted-living facility. Which of the following clients should the nurse determine needs to be seen by a provider immediately?

A client who is taking thioridazine and has daytime drowsiness

A client who is taking olanzapine and experiences dizziness when first standing up

A client who is taking clozapine, and has flu-like manifestations

A client who is taking chlorpromazine and reports vomiting twice

Answer and Explanation

The Correct Answer is C

A. Thioridazine and drowsiness
A common side effect, not urgent.

B. Olanzapine and dizziness
Orthostatic hypotension-monitor, but not emergent.

C. Clozapine and flu-like symptoms
Could indicate agranulocytosis, a life-threatening condition-requires immediate evaluation.

D. Chlorpromazine and vomiting
Requires monitoring, but not as urgent as option C.

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Correct Answer is C

Explanation

A. "I should breathe deeply."
Deep breathing prevents atelectasis and promotes gas exchange.

B. "I should cough frequently."
Frequent coughing helps clear secretions and prevent pneumonia.

C. "I should avoid pain medications as much as possible."
This is incorrect. Adequate pain control is essential for effective breathing and coughing. Pain medications should not be avoided without cause.

D. "I should use an incentive spirometer regularly."
Incentive spirometry is essential to prevent respiratory complications.

A. Apply ice packs to affected leg. B. Massage the client's affected leg twice a day. C. Have the client ambulate prior to applying anti-embolic stockings. D. Keep the client's affected leg elevated while in bed.

Correct Answer is D

Explanation

A. Apply ice packs to affected leg.
Cold therapy is not appropriate for DVT; it can worsen vasoconstriction.

B. Massage the affected leg twice a day.
Contraindicated. Massage can dislodge the clot and cause pulmonary embolism.

C. Have the client ambulate before applying anti-embolic stockings.
Stockings should be applied before ambulation to reduce risk of embolism.

D. Keep the affected leg elevated while in bed.
Promotes venous return, reduces swelling, and is appropriate for DVT management.

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A nurse is caring for several clients who have mental health disorders at an assisted-living facility. Which of the following clients should the nurse determine needs to be seen by a provider immediately?

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