What is the priority finding to report to the provider for a client who has schizophrenia and is taking clozapine?

Sore throat

Heart rate 104/min

Nausea

Random blood glucose 130 mg/dL

Answer and Explanation

The Correct Answer is A

This finding could indicate agranulocytosis, a potentially life threatening adverse effect of clozapine that causes a severe decrease in white blood cells and increases the risk of infection. The other findings are also important to monitor, but they are not as critical as sore throat.

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Correct Answer is B

Explanation

The nurse should have the provider assess the client within 1 hr after applying restraints to ensure that the restraints are necessary and appropriate, and to monitor the client's physical and mental status.

A. Lanugo covering the body B. +2 edema of the lower extremities C. BUN 21 mg/dL D. Blood pH 7.60

Correct Answer is D

Explanation

A blood pH of 7.60 indicates alkalosis, which is a life-threatening condition that can result from vomiting, laxative abuse, or diuretic use in clients who have anorexia nervosa. Alkalosis can cause cardiac arrhythmias, seizures, coma, and death if not corrected promptly. The nurse should notify the provider and prepare to administer IV fluids and electrolytes as ordered. The other findings are also concerning, but they are not as urgent as alkalosis.

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What is the priority finding to report to the provider for a client who has schizophrenia and is taking clozapine?

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Naxlex Comprehensive Predictor Exams

A nurse on a mental health unit placed a client in mechanical restraints after the client assaulted another client. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who has anorexia nervosa. Which of the following findings requires immediate intervention by the nurse?

Correct Answer is D

Explanation

A nurse is caring for a client who has depression following a recent job loss. Which of the following questions should the nurse ask to assess the client's personal coping skills?

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