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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. "Have your child lie down and turn their head to the side for 10 minutes." Lying down increases blood flow to the head, which can worsen the nosebleed or cause aspiration if blood is swallowed. Upright posture is preferred to reduce venous pressure in nasal vessels.
B. "Place a warm, wet washcloth over your child's forehead and the bridge of their nose." Warm compresses can dilate blood vessels and worsen bleeding. Cold compresses are more appropriate to constrict blood vessels and reduce blood flow.
C. "Tell your child to blow their nose gently and then sit down and put their head backward." Blowing the nose can dislodge clots and worsen bleeding. Tilting the head back can cause blood to run down the throat, increasing the risk of nausea, vomiting, or aspiration.
D. "Use your thumb and forefinger to apply pressure to the sides of your child's nose."
Pinching the soft part of the nose for 10–15 minutes while the child leans slightly forward is the first-line intervention for epistaxis. This reduces bleeding and prevents aspiration.
Correct Answer is B
Explanation
Rationale:
A. Tell the client to sit alone in a private place and reflect on the situation: Clients in a panic state are overwhelmed, disorganized, and unable to focus. Leaving them alone can increase feelings of isolation and fear, worsening the anxiety.
B. Use short sentences when communicating with the client: During panic-level anxiety, the client's ability to process information is impaired. Clear, concise communication helps reduce confusion and provides a sense of control and safety.
C. Have the client journal about what is happening to him: Journaling requires introspection and cognitive organization, which are not possible when a client is in a panic state. This intervention is more appropriate once anxiety levels have decreased.
D. Encourage the client to talk about his feelings: While verbalizing emotions is therapeutic, a client in panic may not be able to articulate thoughts. The priority is to first reduce the anxiety to a manageable level using calm, simple guidance.
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