A nurse is assessing a client who is taking clozapine. For which of the following adverse effects should the nurse monitor and report to the provider?
Sore throat
Tinnitus
Rhinitis
Headache
The Correct Answer is A
Rationale:
A. Sore throat: A sore throat may indicate agranulocytosis, a serious adverse effect of clozapine that results in dangerously low white blood cell counts. Early signs include fever, sore throat, and malaise. This requires immediate reporting and evaluation with a complete blood count.
B. Tinnitus: Tinnitus is not a known or common adverse effect of clozapine. While bothersome, it is not typically associated with the hematologic or metabolic risks posed by this antipsychotic medication.
C. Rhinitis: Although rhinitis can occur with many medications, it is not a serious or expected side effect of clozapine requiring urgent attention. Mild nasal symptoms are usually self-limiting and not indicative of life-threatening complications.
D. Headache: Headaches are common and nonspecific symptoms that may result from various causes. Unless severe or persistent, they do not typically indicate a dangerous reaction to clozapine and are not prioritized over signs of infection.
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Related Questions
Correct Answer is D
Explanation
Rationale:
A. Call in additional medical-surgical unit nursing care staff: The initial priority during a mass casualty event is to maximize available resources and free up beds by discharging stable clients. Staffing adjustments come after determining how to expand capacity.
B. Act as a liaison between the facility and the media: This role falls under the responsibilities of public relations or designated administrative personnel. Nurses should focus on patient care and operational tasks relevant to their scope during a crisis.
C. Determine the medical needs of incoming clients through the emergency department: Triage of incoming casualties is performed by designated emergency department staff. Nurses from other units typically assist by creating space or relocating stable clients.
D. Recommend to the provider specific acute care clients for discharge: Identifying stable clients who can be safely discharged allows beds and resources to be allocated to incoming critical cases. This is an appropriate and immediate nursing response during mass casualty.
Correct Answer is A
Explanation
Rationale:
A. Frequent swallowing: Frequent swallowing, especially of small amounts, can indicate that the child is swallowing blood from postoperative bleeding. This is a common early sign of hemorrhage following a tonsillectomy and requires immediate evaluation.
B. Increased drowsiness: Drowsiness can result from anesthesia, pain medication, or fatigue after surgery. While it should be monitored, it is not a specific indicator of postoperative hemorrhage in a child following tonsillectomy.
C. Elevated pain level: Pain is expected after tonsillectomy and does not necessarily signal bleeding. Sudden severe pain might warrant reassessment, but elevated pain alone is not a definitive sign of hemorrhage.
D. Diminished breath sounds: Diminished breath sounds are not typically associated with post-tonsillectomy hemorrhage. This finding may indicate a respiratory issue, but not specifically bleeding from the surgical site.
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