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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "I can expect my eyelids to be bruised after this procedure": Bruising of the eyelids is not a common expectation following cataract removal surgery. While mild redness or irritation may occur, significant bruising is not typical.
B. "I will see dark spots in my vision after this procedure": Seeing dark spots in vision after cataract removal surgery is not expected. The purpose of cataract surgery is to improve vision by removing the cloudy lens and replacing it with a clear artificial lens. Dark spots in vision may indicate complications such as retinal detachment, which should be promptly reported to the healthcare provider.
C. "I will receive general anesthesia for this procedure": Cataract removal surgery typically does not require general anesthesia. Instead, it is commonly performed under local anesthesia with sedation. General anesthesia is reserved for more complex or high-risk procedures. Therefore, this statement indicates a misunderstanding of the anesthesia type for cataract surgery.
D. "I know the provider will replace the lens in my eyes during this procedure": This statement indicates an accurate understanding of the cataract removal procedure. During cataract surgery, the cloudy natural lens of the eye is removed and replaced with an artificial intraocular lens (IOL) to restore vision. This is the primary goal of the surgery, and the statement reflects the client's understanding of the procedure.
Correct Answer is C
Explanation
A. The client reports that the restraints are too tight: This indicates a need for adjustment of the restraints but does not necessarily indicate that the restraints should be discontinued altogether. The client's ability to follow commands and behave safely is a more critical factor in deciding whether to discontinue the restraints.
B. The client has been in the restraints for 4 hours: While prolonged use of restraints should be avoided due to the risk of complications such as skin breakdown and loss of mobility, the duration alone may not be the sole indicator for discontinuing restraints. The client's behavior and ability to follow commands are more important considerations.
C. The client is able to calmly follow commands: This is the most appropriate finding indicating that the restraints should be discontinued. Calmly following commands suggests that the client's behavior has improved and they are no longer a danger to themselves or others, making the restraints unnecessary.
D. The client can explain the reasons for their behavior: While understanding the reasons for the client's behavior is important for addressing underlying issues, it does not necessarily indicate that the client is no longer a risk to themselves or others. The ability to calmly follow commands is a more immediate concern when deciding whether to discontinue restraints.
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