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. "I understand that you are angry, but this behavior will not be tolerated": This response sets a clear boundary regarding unacceptable behavior while acknowledging the client's emotional state. It communicates to the client that their actions are not acceptable, but it does so in a firm yet empathetic manner. This statement also maintains professionalism and ensures a safe and respectful environment for both the client and the nurse.
B. "You are very disrespectful. You need to learn to control yourself": This statement is confrontational and may escalate the client's anger or resistance. It focuses on blaming the client rather than exploring potential modifications to improve the situation.
C. "What behaviors could you modify to improve this situation?":may not be as effective in this context because it places the responsibility solely on the client to modify their behavior without directly addressing the inappropriate actions exhibited. Additionally, individuals with antisocial personality disorder may have difficulty recognizing the impact of their behavior on others or may be resistant to changing their actions without external intervention or consequences.
D. "What anti-personality disorder medications have helped you in the past?": Antisocial personality disorder is not typically treated with specific medications, and individuals with this disorder may not seek or comply with medication interventions. Asking about medications may not be relevant or helpful in addressing the immediate behavioral issues.
Correct Answer is A
Explanation
A. WBC count 3,300/mm³.
Clozapine, an atypical antipsychotic medication, is associated with a risk of agranulocytosis, which is a severe reduction in white blood cell (WBC) count. A WBC count of 3,300/mm³ is significantly below the normal range, and it indicates a contraindication to the use of clozapine.
B. Asthma:
Asthma is not a contraindication to clozapine. However, it is important to monitor respiratory function as antipsychotic medications can have side effects related to respiratory function.
C. Hypertension:
Hypertension alone is not a contraindication to clozapine. Clozapine can, however, be associated with some cardiovascular side effects, so blood pressure should be monitored regularly.
D. Fasting blood glucose 120 mg/dL:
An elevated fasting blood glucose level is not a contraindication to clozapine. However, it is important to monitor metabolic parameters as antipsychotic medications, including clozapine, can be associated with metabolic side effects.
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