A nurse is caring for a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to report to the provider?
Random blood glucose 130 mg/dL.
Heart rate 104/min.
Nausea
Sore throat.
The Correct Answer is D
The correct answer is choice d. Sore throat. Choice A rationale: A random blood glucose level of 130 mg/dL is slightly elevated but not immediately concerning. It should be monitored, especially since clozapine can cause metabolic changes, but it is not the priority. Choice B rationale: A heart rate of 104/min is slightly elevated and could be a side effect of clozapine, which can cause tachycardia. However, it is not as urgent as other potential side effects. Choice C rationale: Nausea is a common side effect of many medications, including clozapine. While uncomfortable, it is not typically a priority concern unless it leads to severe dehydration or other complications. Choice D rationale: A sore throat can be a sign of agranulocytosis, a potentially life-threatening condition where the white blood cell count drops dangerously low. Clozapine is known to cause this condition, and it requires immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A.Weighing the client every other day might not be appropriate in this case. Individuals with binge eating disorder often struggle with body image issues, and focusing on weight can exacerbate these concerns and contribute to a negative psychological state.
B. Remain with the client for 1 hr after meals: This can help prevent the client from engaging in purging behaviors after eating.
C.Involving the client in meal planning can help them feel more in control and promote healthier eating habits.While meal planning can be beneficial, it's not the most immediate action needed in this situation.
D.Offering snacks when the client is hungry can potentially worsen the disorder. Clients with binge eating disorder often struggle with impulse control and may have difficulty stopping themselves from overeating. Providing unlimited access to snacks may reinforce unhealthy eating patterns.
Correct Answer is C
Explanation
Nurses have an ethical and legal responsibility to maintain the privacy and confidentiality of a client’s personal and health information obtained in the context of the therapeutic nurse-client relationship.There is both federal and provincial legislation to protect a client’s personal and health information, such as the Health Insurance Portability and Accountability Act (HIPAA) and the HIPAA Privacy Rule in the United States.Nurses should only disclose a client’s information to those who have a need to know, such as other health care providers involved in the client’s care, or with the client’s consent.
Based on this information, the appropriate nursing action when the client’s employer calls to discuss the client’s condition is toconsult the client. The nurse should ask the client if they want to share any information with their employer, and respect their wishes.The nurse should not contact the provider, the facility legal department, or the client’s family without the client’s permission, unless there is a legal obligation or a substantial risk of harm to the client or others
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