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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
A. To emphasize that the client is capable of consuming food without purging: This is the correct purpose of the intervention. By recalling a time when the client was able to consume food without engaging in purging behaviors, the nurse aims to highlight the client's capability to eat without resorting to unhealthy practices.
B. To incorporate specific foods into the meal plan to reflect pleasant memories: While incorporating pleasant memories into the meal plan can be a positive aspect of treatment, the primary purpose of the intervention described is to focus on the client's ability to eat without purging.
C. To assist the client to become more compliant with the treatment plan: While promoting compliance with the treatment plan is important, the specific intervention described is more about exploring the client's past experiences with eating without purging to reinforce the possibility of achieving healthier eating habits.
D. To gain additional information about the progression of the disease process: The intervention is not primarily aimed at gaining information about the progression of the disease process. Instead, it is focused on emphasizing the client's capacity to eat without engaging in purging behaviors.
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