A nurse is developing a care plan for a client who has schizophrenia and is taking chlorpromazine. Which of the following actions should the nurse include in the plan?

Weigh the client daily.

Monitor the client for signs of bleeding.

Monitor the client’s respirations every 4 hours.

Administer an antacid with the medication to decrease nausea.

Answer and Explanation

The Correct Answer is A

Choice A reason: Weigh the client daily is important because chlorpromazine can cause weight gain as a side effect. Regular monitoring of the client’s weight helps in managing and mitigating this potential adverse effect.

Choice B reason: Monitor the client for signs of bleeding is not typically necessary for clients taking chlorpromazine. This medication does not commonly cause bleeding issues. Monitoring for bleeding would be more relevant for clients on anticoagulants or medications that affect platelet function.

Choice C reason: Monitor the client’s respirations every 4 hours is not specifically required for clients on chlorpromazine. While respiratory depression can be a concern with some medications, it is not a common side effect of chlorpromazine.

Choice D reason: Administer an antacid with the medication to decrease nausea is not recommended. Antacids can interfere with the absorption of chlorpromazine, reducing its effectiveness. If the client experiences nausea, other antiemetic strategies should be considered.

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Correct Answer is ["A","B","D"]

Explanation

Choice A: Time the duration of the seizure

Reason: Timing the duration of a seizure is crucial for several reasons. Firstly, it helps in determining the type of seizure and its severity. Seizures lasting more than 5 minutes are considered medical emergencies and may require immediate intervention to prevent complications such as status epilepticus, which is a prolonged seizure that can cause brain damage or death. By recording the start and end times, healthcare providers can assess the effectiveness of treatments and make necessary adjustments. Additionally, this information is vital for documenting the patient’s medical history and for future reference in managing the condition.

Choice B: Administer supplemental oxygen to the client

Reason: Administering supplemental oxygen is essential during a seizure, especially when the client’s oxygen saturation levels drop below the normal range of 95-100%. In the provided scenario, the client’s oxygen saturation is 86%, which is significantly low and indicates hypoxemia. Hypoxemia can lead to further complications, including brain damage due to insufficient oxygen supply. Providing supplemental oxygen helps maintain adequate oxygen levels in the blood, ensuring that vital organs, including the brain, receive enough oxygen to function properly. This intervention is critical in preventing hypoxic injuries and promoting recovery post-seizure.

Choice C: Place a tongue depressor in the client’s mouth

Reason: Placing a tongue depressor in the client’s mouth during a seizure is not recommended and can be dangerous. This outdated practice was once believed to prevent the client from biting their tongue, but it poses significant risks. The client could bite down on the depressor, causing dental injuries or even breaking the depressor, leading to choking hazards. Modern seizure management guidelines advise against placing any objects in the mouth during a seizure. Instead, the focus should be on ensuring the client’s safety by clearing the area of any harmful objects and positioning them safely.

Choice D: Turn the client to the side

Reason: Turning the client to the side, also known as the recovery position, is a critical intervention during a seizure. This position helps maintain an open airway and reduces the risk of aspiration, which can occur if the client vomits or has excessive saliva. Aspiration can lead to serious respiratory complications, including pneumonia. By positioning the client on their side, gravity helps drain fluids from the mouth, preventing them from entering the airway9. This simple yet effective measure is a standard practice in seizure management to ensure the client’s safety and comfort.

Choice E: Restrain the client

Reason: Restraining a client during a seizure is not recommended and can be harmful. Seizures involve involuntary muscle contractions, and attempting to restrain the client can lead to injuries such as fractures, muscle tears, or dislocations. Additionally, restraint can increase the client’s agitation and stress, potentially worsening the seizure. The appropriate approach is to ensure the client’s safety by removing nearby objects that could cause injury and allowing the seizure to run its course. Gentle guidance and support should be provided without applying force.

A. Long attention span B. Delayed language development C. Speaking with direct eye contact D. Repetitive behavior E. Playing with toys repetitively

Correct Answer is ["B","D","E"]

Explanation

Choice A reason:

The statement “Long attention span” is generally not associated with autism spectrum disorder (ASD). Children with ASD often have difficulty maintaining attention on tasks or activities, especially those that do not interest them. They may exhibit hyperfocus on specific interests but typically struggle with sustained attention in other areas.

Choice B reason:

The statement “Delayed language development” is a common characteristic of ASD. Many children with autism experience delays in speech and language skills. They may have difficulty with verbal communication, understanding language, and using language in social contexts. This delay can vary widely among individuals with ASD.

Choice C reason:

The statement “Speaking with direct eye contact” is not typically associated with ASD. Children with autism often avoid direct eye contact and may find it uncomfortable or overwhelming. They might look away or use peripheral vision instead of making direct eye contact during conversations.

Choice D reason:

The statement “Repetitive behavior” is a hallmark of ASD. Children with autism often engage in repetitive behaviors, such as hand-flapping, rocking, or repeating certain actions or phrases. These behaviors can be a way to self-soothe or cope with sensory overload.

Choice E reason:

The statement “Playing with toys repetitively” is also characteristic of ASD. Children with autism may play with toys in a repetitive manner, such as lining them up, spinning them, or focusing on specific parts of the toy rather than using them in imaginative play. This repetitive play is part of the broader pattern of repetitive behaviors seen in ASD.

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A nurse is developing a care plan for a client who has schizophrenia and is taking chlorpromazine. Which of the following actions should the nurse include in the plan?

Nursing Test Bank

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Explanation

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