A nurse is caring for a client diagnosed with schizophrenia following a recent suicide attempt. Which of the following actions should the nurse take?
Place metal utensils on the client's meal tray.
Assign the client to a private room.
Inspect the client's personal belongings.
Tuck bedcovers over client's hands and arms.
The Correct Answer is C
A) Incorrect. Placing metal utensils on the client's meal tray may pose a safety risk, especially considering the recent suicide attempt.
B) Incorrect. Assigning the client to a private room may be beneficial for privacy, but the more immediate concern is ensuring the safety of the client by inspecting personal belongings.
C) Correct. Inspecting the client's personal belongings is crucial to remove any potentially harmful items that the client may use to harm themselves.
D) Incorrect. Tucking bedcovers over the client's hands and arms is not a specific intervention related to the recent suicide attempt.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct. Tardive dyskinesia is a side effect of long-term neuroleptic (antipsychotic) treatment. It is characterized by involuntary, repetitive movements, particularly of the face and tongue. This condition is more commonly seen in clients who have been on neuroleptics for extended periods.
B) Incorrect. Discontinuing neuroleptic treatment may lead to withdrawal symptoms or symptom recurrence, but it does not directly increase the risk of developing tardive dyskinesia.
C) Incorrect. Neuroleptic malignant syndrome (NMS) is a different side effect associated with neuroleptic medications, characterized by hyperthermia, autonomic dysregulation, altered mental status, and generalized muscle rigidity.
D) Incorrect. Monoamine oxidase inhibitors (MAOIs) are a different class of medications and are not associated with the development of tardive dyskinesia.
Correct Answer is D
Explanation
A. Kidney function studies While monitoring kidney function is important for clients on certain medications, it is not the primary laboratory test for monitoring clozapine. Clozapine is associated with agranulocytosis, which affects white blood cell count.
B. Red blood cell count Monitoring red blood cell count is not the primary concern when a client is prescribed clozapine. The main concern with clozapine is agranulocytosis, which affects white blood cells.
C. Liver function studies While liver function is important to monitor with some medications, it is not the primary laboratory test for monitoring clozapine. The primary concern with clozapine is agranulocytosis, which affects white blood cell count.
D. White blood cell count Clozapine is associated with agranulocytosis, a potentially life- threatening condition characterized by a severe decrease in white blood cells. Regular
monitoring of white blood cell count is crucial to detect and prevent this adverse effect. This test should be performed before starting clozapine and regularly throughout treatment. If the white blood cell count drops significantly, clozapine may need to be discontinued. This makes it the
most important laboratory study to monitor when a client is prescribed clozapine.
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