A client who has been taking clozapine reports experiencing a sore throat and has a temperature of 101.9° F (38.8° C). Which action should the nurse take?

Encourage Increase Intake of oral fluids.

Obtain a specimen for a complete blood count.

Complete an Abnormal Involuntary Movement Scale (AIMS).

Administer a PRN dose of acetaminophen.

Answer and Explanation

The Correct Answer is B

Choice A rationale: Encouraging an increase in oral fluids is a general intervention but may not address the specific concern related to a sore throat and elevated temperature.

Clozapine requires monitoring for potential agranulocytosis, and an infection should be ruled out with a complete blood count (CBC).

Choice B rationale: Obtaining a specimen for a complete blood count (CBC) is crucial to assess for clozapine-induced agranulocytosis, a potentially life-threatening side effect. A sore throat and fever are red flags for possible infection.

Choice C rationale: Completing an Abnormal Involuntary Movement Scale (AIMS) is not relevant to the current situation. A sore throat and fever require immediate attention to rule out infection.

Choice D rationale: Administering a PRN dose of acetaminophen may help reduce fever, but the priority is to investigate the potential cause of the symptoms. Obtaining a CBC is essential.

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Correct Answer is B

Explanation

Choice A rationale: Referring the client to the cardiology clinic may be necessary, but obtaining the client's blood pressure is the priority to assess the immediate need for intervention and determine the appropriate course of action.

Choice B rationale: Obtaining the client's blood pressure is the most immediate and relevant action. Chest pain is a potentially serious symptom, and assessing blood pressure will help determine the urgency of the situation.

Choice C rationale: Determining if alprazolam was taken recently is important but may not be the immediate priority when the client is reporting chest pain. Assessing vital signs is crucial in this situation.

Choice D rationale: Assessing the client for substance abuse is relevant to the overall care of the client but may not be the immediate priority when chest pain is reported. The nurse should address potential medical emergencies first.

A. Tell the client they are out of control. B. Stay quietly with the client. C. Distract the client by offering finger foods. D. Ignore the client's acting out behavior.

Correct Answer is B

Explanation

Choice A rationale: Telling the client they are out of control may escalate the situation and provoke further aggression. It is not a therapeutic or de-escalation technique.

Choice B rationale: Staying quietly with the client is a calm and non-confrontational approach. It allows the client to express emotions while conveying a supportive presence.

Choice C rationale: Distracting the client by offering finger foods may not be appropriate during a shouting episode, as it may be perceived as dismissive of the client's feelings or concerns.

Choice D rationale: Ignoring the client's acting-out behavior is not the best option. The nurse should acknowledge the client's emotions and provide support rather than ignoring the distress.

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A client who has been taking clozapine reports experiencing a sore throat and has a temperature of 101.9° F (38.8° C). Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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