While assessing a client with the diagnosis of schizophrenia who wears dentures, the nurse observes that the client’s tongue is “worming”. The client also demonstrates an inability to articulate words clearly. Which additional assessment is most important for the nurse to obtain?

Usual level of activity and average sleep pattern.

Blood pressure when sitting and standing.

Dentures to determine if they are poorly fitted.

Body weight over the past three months.

Answer and Explanation

The Correct Answer is C

A.   Assessing the usual level of activity and average sleep pattern is relevant but does not directly address the observed symptoms related to speech and tongue movements.
B.   Blood pressure assessment is important for overall health monitoring but is not the most immediate concern related to the observed speech and tongue abnormalities.
C. Assessing the fit of dentures is crucial in this context, as poorly fitted dentures could contribute to speech difficulties and tongue abnormalities.
D.   Body weight assessment is important for overall health but is not the most immediate concern in this situation. Assessing denture fit addresses the observed speech and tongue abnormalities more directly.

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Correct Answer is D

Explanation

A. While sore throat and fever can be potential side effects of clozapine, informing UAP is not a proactive intervention. Regular monitoring of white blood cell (WBC) counts is crucial for
detecting clozapine-induced agranulocytosis.
B. Protective isolation is not a standard practice for clients taking clozapine. Monitoring for specific side effects, such as agranulocytosis, is more important.
C. Offering clozapine with food is not a priority intervention for managing potential side effects.
Monitoring and reporting WBC counts take precedence.
D. Clozapine is associated with the risk of agranulocytosis. Regular monitoring of WBC counts is essential, and any findings outside the normal range should be promptly reported to the
healthcare provider.

A. A summary of the client’s feelings B. The client’s significant other’s statement C. A general description D. Photographs

Correct Answer is D

Explanation

A. Documenting the client’s feelings is important but may not provide objective evidence of injuries.
B. The significant other’s statement may be biased and may not accurately represent the client's injuries.
C. A general description may lack specificity, making it difficult to convey the extent and nature of the injuries.
D. Photographs are objective and provide visual documentation of the injuries, offering a clear and accurate record for legal and healthcare purposes.

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While assessing a client with the diagnosis of schizophrenia who wears dentures, the nurse observes that the client’s tongue is “worming”. The client also demonstrates an inability to articulate words clearly. Which additional assessment is most important for the nurse to obtain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to an inpatient psychiatric unit, and the antipsychotic medication clozapine is prescribed. Which intervention should the nurse include in this client’s plan of care?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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