A nurse is caring for a client who is taking clozapine. Which of the following findings should the nurse report to the provider?

Tinnitus

Dizziness

Sore throat

Diaphoresis

Answer and Explanation

The Correct Answer is C

Rationale:

A. Tinnitus: Tinnitus is not a known or common adverse effect of clozapine. While it may indicate another condition, it does not require immediate reporting in the context of clozapine therapy.

B. Dizziness: Dizziness can occur due to clozapine’s hypotensive effects, especially when initiating therapy. It is usually self-limiting and managed symptomatically unless it worsens or affects safety.

C. Sore throat: A sore throat can signal the onset of agranulocytosis, a life-threatening side effect of clozapine marked by a dangerously low white blood cell count. It must be reported immediately for prompt blood count evaluation.

D. Diaphoresis: Diaphoresis may occur with many medications and is not specific to clozapine toxicity or serious adverse effects. It typically does not warrant immediate reporting unless severe or part of a broader concerning symptom complex.

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Correct Answer is B

Explanation

Rationale:

A. Buy disposable dishes for daily use: HIV is not transmitted through saliva or casual household contact, including sharing dishes. Disposable dishes are unnecessary and promote stigma.

B. Clean blood-contaminated surfaces with bleach: A 1:10 bleach solution is effective in killing HIV on surfaces. Proper cleaning of blood spills is essential for preventing transmission.

C. Wash soiled clothes in cold water: Hot water (not cold) and detergent should be used to clean potentially contaminated clothing to reduce the risk of infection.

D. Use condoms with a petroleum-based lubricant: Petroleum-based lubricants degrade latex condoms, increasing the risk of breakage. Water- or silicone-based lubricants should be used instead.

A. Slow change in dilation and effacement B. Contraction intensity increased by ambulation C. Presence of bloody show D. Intermittent, painless contractions

Correct Answer is D

Explanation

Rationale:

A. Slow change in dilation and effacement: Even slow cervical changes are indicative of true labor. False labor does not cause any progressive cervical dilation or effacement, making this an inconsistent finding for false labor.

B. Contraction intensity increased by ambulation: In true labor, contractions typically intensify with activity such as walking. In contrast, false labor contractions often diminish or resolve with changes in position or ambulation.

C. Presence of bloody show: Bloody show results from cervical dilation and the disruption of cervical capillaries. It is a hallmark of true labor and would not be expected during false labor.

D. Intermittent, painless contractions: False labor is characterized by irregular, non-progressive, and typically painless contractions, often referred to as Braxton Hicks contractions. These are normal in late pregnancy but do not indicate true labor.

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A nurse is caring for a client who is taking clozapine. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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