A nurse is reviewing the medical record of a 50-year-old male client who has schizophrenia in an inpatient mental health facility
Which of the following findings should the nurse report to the provider? (Select all that apply.)
Blood glucose level
WBC count
Temperature
Blood pressure
Correct Answer : A,B,C
Choice A rationale: Blood glucose level
A blood glucose level of 200 mg/dL is elevated, suggesting possible hyperglycemia. Clozapine, an atypical antipsychotic, can cause metabolic effects, including insulin resistance, leading to diabetes. This warrants further evaluation by the provider to determine if glucose monitoring or treatment adjustments are needed.
Choice B rationale: WBC count
A WBC count of 4,800/mm³ is low, which is concerning because clozapine can cause agranulocytosis, a severe condition where white blood cells drop significantly, increasing the risk of infection. Since the client is on clozapine, the provider must be informed to assess the need for additional lab monitoring or medication adjustments.
Choice C rationale: Temperature
A temperature of 37.8°C (100.0°F) may indicate a mild fever, which is concerning in the context of a low WBC count. Since clozapine increases infection risk due to potential agranulocytosis, this temperature should be reported to rule out an underlying infection.
Choice D rationale: Blood pressure
A blood pressure of 110/68 mm Hg is within the normal range and does not warrant immediate intervention. It is not concerning in this case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["15"]
Explanation
Step 1 is: Determine the desired dose: 7.5 mg.
Step 2 is: Determine the concentration on hand: 2.5 mg ÷ 5 mL.
Step 3 is: Set up the calculation: (7.5 mg × 5 mL) ÷ 2.5 mg.
Step 4 is: Perform the multiplication: 37.5 mg·mL ÷ 2.5 mg.
Step 5 is: Perform the division: 15 mL.
Final answer: The nurse should administer 15 mL.
Correct Answer is B
Explanation
Choice A rationale
Repeated school absences are a common finding in conduct disorder and indicate a disregard for rules and obligations. While important to address, it does not represent an immediate safety risk compared to threats of harm.
Choice B rationale
Threats of injury to others indicate a potential for violence and pose an immediate safety risk to others. This requires the nurse's immediate attention to assess the situation, ensure safety, and implement appropriate interventions to prevent harm.
Choice C rationale
Lack of empathy for others is a core characteristic of conduct disorder, reflecting a difficulty in understanding or sharing the feelings of others. While significant for long-term management, it does not present an immediate safety concern.
Choice D rationale
A history of shoplifting indicates a pattern of rule-breaking and disregard for the rights of others, which is characteristic of conduct disorder. However, it does not represent an immediate threat of harm compared to threats of injury.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.