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 B

Explanation

Choice A reason: Hyperlipidemia

Hyperlipidemia, or high levels of lipids in the blood, can be a contributing factor to acute pancreatitis. Elevated triglycerides can lead to the development of pancreatitis, especially when levels exceed 1000 mg/dL. However, it is less common compared to gallstones and alcohol abuse as a cause of acute pancreatitis.

Choice B reason: Gallstones

Gallstones are one of the most common causes of acute pancreatitis. They can block the bile duct, leading to a buildup of pancreatic enzymes and subsequent inflammation of the pancreas. This condition, known as gallstone pancreatitis, accounts for a significant percentage of acute pancreatitis cases. Therefore, it is crucial for the nurse to inquire about a history of gallstones when assessing a client with acute pancreatitis.

Choice C reason: COPD

Chronic Obstructive Pulmonary Disease (COPD) is not directly related to the development of acute pancreatitis. While COPD is a significant chronic condition that affects the lungs, it does not have a known association with pancreatitis. Therefore, this factor is less relevant in the context of acute pancreatitis.

Choice D reason: Diabetes mellitus

Diabetes mellitus can be both a consequence and a risk factor for pancreatitis. Chronic pancreatitis can lead to diabetes due to the damage to insulin-producing cells in the pancreas. However, diabetes itself is not a common cause of acute pancreatitis. It is more relevant in the context of chronic pancreatitis and its complications.

A. Heart rate B. Blood pressure C. Urine output D. Weight

Correct Answer is A

Explanation

Choice A reason:

A decrease in heart rate is a key indicator of adequate fluid resuscitation in burn patients. When a patient is adequately hydrated, the heart does not need to work as hard to pump blood, leading to a lower heart rate. This is because fluid resuscitation helps restore blood volume, improving cardiac output and reducing the strain on the heart. Normal heart rate ranges for adults are typically between 60-100 beats per minute.

Choice B reason:

While blood pressure is an important parameter to monitor, a decrease in blood pressure is not an indication of adequate fluid replacement. In fact, adequate fluid resuscitation should help maintain or increase blood pressure to normal levels. Low blood pressure could indicate hypovolemia or inadequate fluid resuscitation3. Normal blood pressure ranges are generally considered to be around 120/80 mmHg.

Choice C reason:

A decrease in urine output is not a sign of adequate fluid resuscitation. On the contrary, adequate fluid replacement should result in an increase in urine output as the kidneys receive sufficient blood flow to filter and excrete waste products. Urine output is a critical marker for assessing fluid balance, with normal output being about 0.5-1 mL/kg/hr.

Choice D reason:

A decrease in weight is not an immediate indicator of adequate fluid resuscitation. Weight changes can occur over a longer period and are influenced by various factors, including fluid shifts, edema, and overall fluid balance. In the acute phase of burn management, more immediate indicators like heart rate and urine output are more reliable.

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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

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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