A client presents to the clinic for a postoperative follow-up following surgical repair of a fractured radius.

The client reports their adult child prepares two meals a day for them to eat.

The client's weight is 55.9 kg (123 Ib) and height is 175 cm (69 in). What is the client's BMI?

Choice A rationale

Diarrhea is a common side effect of clozapine, a second-generation antipsychotic medication. It is usually a mild to moderate symptom and does not typically warrant immediate reporting to the provider unless it is severe, persistent, or accompanied by other concerning symptoms like dehydration. It can often be managed with dietary adjustments or over-the-counter antidiarrheal medications, and it does not usually indicate a serious or life-threatening adverse reaction.

Choice B rationale

A fever in a client taking clozapine is a critical finding that must be immediately reported to the provider. Fever can be an early symptom of agranulocytosis, a severe and potentially fatal adverse effect characterized by a dangerously low white blood cell count. Agranulocytosis makes the client highly susceptible to severe infections. A fever may also indicate the onset of neuroleptic malignant syndrome, another serious and life-threatening condition.

Choice C rationale

Polyuria, which is excessive urination, can be a symptom of various conditions but is not a primary concern or contraindication for clozapine administration. It can be associated with increased fluid intake due to xerostomia (dry mouth), a common side effect of clozapine. It does not typically indicate a severe, life-threatening adverse effect like agranulocytosis or neuroleptic malignant syndrome, and thus does not require immediate reporting.

Choice D rationale

Diaphoresis, or excessive sweating, is a frequent side effect of clozapine. It is often related to the drug's anticholinergic effects and thermoregulatory dysfunction. While it can be uncomfortable for the client and may require management, it is not an immediate sign of a life-threatening condition like agranulocytosis or neuroleptic malignant syndrome. Therefore, it does not typically require an immediate report to the provider. *.

Choice A rationale

Using clean technique for invasive procedures in a neutropenic client is insufficient. Neutropenia is a severe reduction in neutrophils, a key component of the immune system, leaving the client highly susceptible to infection. Aseptic or sterile technique, rather than clean technique, is necessary for all invasive procedures to prevent the introduction of pathogens. This includes strict hand hygiene, sterile gloves, and sterile fields to minimize infection risk.

Choice B rationale

Allowing healthy children to visit is a dangerous practice for a neutropenic client. Children, even those appearing healthy, can carry and transmit pathogens like viruses and bacteria that their developing immune systems can easily fight off. In a client with neutropenia, however, these common microorganisms can cause severe, life-threatening infections due to the lack of an adequate immune response. Therefore, visitors must be carefully screened.

Choice C rationale

Cleaning the client's room every 2 days is an inadequate frequency for a neutropenic client. An environment with reduced pathogen exposure is crucial for these immunocompromised clients. The room should be cleaned daily to minimize the accumulation of dust, dirt, and microorganisms. All surfaces, including floors, tables, and equipment, must be disinfected to reduce the risk of nosocomial infections and maintain a sterile environment.

Choice D rationale

Neutropenia impairs the body's ability to mount a fever response to infection. Therefore, a low-grade temperature elevation may be the only sign of a serious infection. Monitoring the client's temperature frequently, typically every 4 hours, is a critical nursing intervention. Early detection of a fever, even a slight one, allows for prompt initiation of antibiotics and other treatments, significantly improving the client's prognosis and preventing a potential septic shock. *.