A nurse is assessing a client who has schizophrenia prior to administering the client's next dose of clozapine. Which of the following findings should the nurse report to the provider?

Diaphoresis

Fever

Polyuria

Diarrhea

Answer and Explanation

The Correct Answer is B

A. Diaphoresis: Diaphoresis, or excessive sweating, is a common side effect of clozapine and may not necessarily indicate a need for immediate intervention. However, it should be documented and monitored for any changes.
B. Fever: Fever can be a sign of infection, which is a serious concern in clients taking clozapine due to the risk of agranulocytosis, a potentially life-threatening side effect characterized by a severe decrease in white blood cell count. Any signs of infection, including fever, should be reported promptly to the provider for further evaluation and management.
C. Polyuria: Polyuria, or excessive urination, is not typically associated with clozapine use and may be indicative of other underlying issues such as diabetes mellitus or diabetes insipidus. While it should be assessed and managed appropriately, it is not specifically related to clozapine administration and may not require immediate reporting to the provider.
D. Diarrhea: Diarrhea is a common gastrointestinal side effect of clozapine and may occur due to its effects on the gastrointestinal system. While persistent or severe diarrhea should be monitored and managed, it is not typically considered a serious adverse reaction that requires immediate reporting to the provider unless it is accompanied by other concerning symptoms.

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Correct Answer is A

Explanation

Answer: A

Rationale: A) "Empty your ostomy pouch when it is half full.": This instruction is essential to prevent the pouch from becoming too heavy, which can cause leakage or discomfort. Regular emptying also helps maintain the integrity of the pouching system and prevents leaks.

B) "Notify the provider if your stoma becomes pink and moist.": While it's crucial to monitor the stoma's appearance for signs of complications, a pink and moist stoma typically indicates healthy tissue. This instruction may cause unnecessary concern for the client.

C) "Use a moisturizing soap to cleanse your stoma.": Moisturizing soap is not recommended for stoma cleansing, as it may leave a residue that interferes with the pouch's adhesion and can lead to skin irritation. Instead, the client should use warm water and a mild, non-moisturizing soap.

D) "Apply sterile gloves when changing your ostomy pouch.": While hand hygiene is essential when managing an ostomy, sterile gloves are not necessary for routine pouch changes. Clean, non-sterile gloves or thorough handwashing with soap and water are sufficient to prevent infection.

A. Wear a bra with wire support. B. Use deodorant under the affected arm. C. Begin ball squeezing exercises. D. Avoid using the affected arm for eating.

Correct Answer is D

Explanation

A. Wear a bra with wire support: This is not recommended immediately after a modified radical mastectomy, as it can put pressure on the surgical site and cause discomfort or interfere with healing. Instead, the client should wear a soft, supportive bra without underwire to provide comfort and support.
B. Use deodorant under the affected arm: Applying deodorant under the affected arm is generally not recommended immediately after surgery, as the area may be sensitive and the skin may be healing. The client should avoid applying deodorant until the surgical site has healed and they have consulted with their healthcare provider.
C. Begin ball squeezing exercises: While exercises to improve range of motion and strength in the affected arm are important after a mastectomy, initiating them on the first day postoperative may be too early. The client should follow the specific instructions provided by their healthcare provider regarding when to begin exercises and which exercises are appropriate.
D. Avoid using the affected arm for eating: This is the most appropriate instruction for the client. After a modified radical mastectomy, the affected arm may be temporarily restricted in movement or may be sensitive. To avoid strain or discomfort, the client should avoid using the affected arm for activities such as eating until they receive further guidance from their healthcare provider.

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A nurse is assessing a client who has schizophrenia prior to administering the client's next dose of clozapine. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who has a new ostomy. Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

A nurse is providing discharge teaching to a client who is 1 day postoperative following a right modified radical mastectomy. Which of the following instructions should the nurse include in the teaching?

Correct Answer is D

Explanation

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