A client diagnosed with schizophrenia is prescribed clozapine (Clozaril). Which client symptoms related to the side effects of this medication should prompt a nurse to intervene immediately?

Dry mouth and urinary retention

Akinesia and insomnia

Sore throat, fever, and malaise

Akathisia and hypersalivation

Answer and Explanation

The Correct Answer is C

A. Dry mouth and urinary retention: These symptoms are not typically associated with the side effects of clozapine. Dry mouth is a common side effect of many antipsychotic medications, but urinary retention is not a typical side effect of clozapine.

B. Akinesia and insomnia: Akinesia (lack of movement) is not a common side effect of clozapine. Insomnia can occur with various antipsychotic medications but does not typically warrant immediate intervention unless severe or persistent.

C. Sore throat, fever, and malaise: These symptoms can indicate a potentially serious side effect known as agranulocytosis, which is a significant reduction in white blood cell count. Clozapine is associated with an increased risk of agranulocytosis. If a client experiences symptoms such as sore throat, fever, or malaise, it may indicate a severe drop in white blood cell count, and immediate medical attention is necessary.

D. Akathisia and hypersalivation: Akathisia (restlessness) is a known side effect of antipsychotic medications, but it is not typically associated with immediate severe medical risks. Hypersalivation is a common side effect but does not usually require immediate intervention unless severe.

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Correct Answer is C

Explanation

A. Teaching clients about their illness: This function is within the scope of practice for both registered nurses and advanced practice psychiatric nurses. Registered nurses often provide education to clients about their illnesses, medications, and overall care.

B. Maintaining safety on the milieu: Both registered nurses and advanced practice psychiatric nurses are responsible for maintaining safety on the milieu. This includes monitoring the environment, assessing potential risks, and intervening to ensure the safety of clients and staff.

C. Prescribing medications: This function is exclusive to advanced practice psychiatric nurses, such as psychiatric nurse practitioners. Registered nurses do not have the authority to prescribe medications. Advanced practice psychiatric nurses receive additional education and training that allows them to prescribe medications as part of their role.

D. Administering medications: Registered nurses, including those specializing in psychiatric nursing, are authorized to administer medications. This is a common nursing function and does not require advanced practice authorization.

A. Self-destructive behavior despite alternative interventions B. Discipline for throwing objects at staff C. Punishment for verbally abusing other clients D. Coercion to take prescribed medications

Correct Answer is A

Explanation

A. Self-destructive behavior despite alternative interventions: Mechanical restraints may be considered when a client poses an immediate risk of harm to themselves, and alternative interventions have been ineffective or are not feasible.

B. Discipline for throwing objects at staff: Mechanical restraints are not appropriate as a form of discipline. Restraints should only be used when there is an imminent risk of harm to the client or others.

C. Punishment for verbally abusing other clients: The use of restraints as a form of punishment is not ethical or appropriate. Restraints should be employed solely to prevent harm, not as a disciplinary measure.

D. Coercion to take prescribed medications: Coercion to take medications is not a valid reason for using mechanical restraints. Alternative approaches, such as therapeutic communication or discussing the need for medications with the client, should be explored.

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A client diagnosed with schizophrenia is prescribed clozapine (Clozaril). Which client symptoms related to the side effects of this medication should prompt a nurse to intervene immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Within the nurse's scope of practice, which function is exclusive to the advanced practice psychiatric nurse?

Correct Answer is C

Explanation

A nurse is discussing the use of mechanical restraints with a newly licensed nurse. Which of the following situations should the nurse include as an indication for placing a client in mechanical restraints?

Correct Answer is A

Explanation

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