A nurse is reviewing the medical record of a 50-year-old male client who has schizophrenia in an inpatient mental health facility

Exhibits

Which of the following findings should the nurse report to the provider? (Select all that apply.)

Blood glucose level

WBC count

Temperature

Blood pressure

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that protects the privacy and security of individuals' health information. Discussing a client's diagnosis in a public place like the cafeteria with someone not involved in their care constitutes a breach of confidentiality under HIPAA.

Choice B rationale

The Good Samaritan Act offers legal protection to individuals who provide assistance in an emergency situation. It is not relevant to the discussion of a client's private health information by healthcare personnel in a non-emergency setting.

Choice C rationale

The Occupational Safety and Health Act (OSHA) ensures safe and healthful working conditions for employees. It does not pertain to the confidentiality of patient health information.

Choice D rationale

The Patient Protection and Affordable Care Act aims to increase the quality and affordability of health insurance, expand public and private insurance coverage, and reduce the costs of healthcare. It does not directly address the confidentiality of patient information in the context described. .

NGN NGN NGN

A. Implement 24-hr one-to-one nursing observation. B. Restrict interactions with other clients. C. Document the client's behavior every 2 hr. D. Administer prescribed medication via the IM route.

Correct Answer is A

Explanation

Choice A rationale

Implementing 24-hr one-to-one nursing observation is a necessary precaution for a newly admitted adolescent who overdosed on prescription pain medication. This close monitoring allows for continuous assessment of the client's physical and mental status, early detection of any complications, and prevention of further self-harm attempts, especially given the prescriptions for an anxiolytic and an SSRI, which could have delayed or paradoxical effects in an overdose situation.

Choice B rationale

Restricting interactions with other clients might increase the adolescent's feelings of isolation and depression, which could be counterproductive to their mental health recovery. Therapeutic interactions with peers can be beneficial.

Choice C rationale

Documenting the client's behavior every 2 hr is a standard nursing practice, but it is not sufficient for a client at high risk for self-harm following an overdose. Continuous observation provides immediate intervention capability.

Choice D rationale

Administering prescribed medication via the IM route is not necessarily a standard precaution for an overdose. The route of administration depends on the specific medication and the client's condition. Oral administration is usually preferred when the client is stable and can tolerate it.

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A nurse is reviewing the medical record of a 50-year-old male client who has schizophrenia in an inpatient mental health facility Exhibits Which of the following findings should the nurse report to the provider? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse overhears assistive personnel (AP) in the cafeteria discussing a client's diagnosis of anorexia nervosa.The nurse should inform the AP that they have breached which of the following legal acts?

Correct Answer is A

Explanation

A nurse in a mental health facility is caring for an adolescent who is newly admitted for an overdose of prescription pain medication.The client has prescriptions for an anxiolytic and an SSRI antidepressant.Which of the following precautions should the nurse take?

Correct Answer is A

Explanation

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A nurse is reviewing the medical record of a 50-year-old male client who has schizophrenia in an inpatient mental health facility

Exhibits

Which of the following findings should the nurse report to the provider? (Select all that apply.)