A nurse is developing a care plan for a client who has schizophrenia and is taking chlorpromazine. Which of the following actions should the nurse include in the plan?
Weigh the client daily.
Monitor the client for signs of bleeding.
Monitor the client’s respirations every 4 hours.
Administer an antacid with the medication to decrease nausea.
The Correct Answer is A
Choice A reason: Weigh the client daily is important because chlorpromazine can cause weight gain as a side effect. Regular monitoring of the client’s weight helps in managing and mitigating this potential adverse effect.
Choice B reason: Monitor the client for signs of bleeding is not typically necessary for clients taking chlorpromazine. This medication does not commonly cause bleeding issues. Monitoring for bleeding would be more relevant for clients on anticoagulants or medications that affect platelet function.
Choice C reason: Monitor the client’s respirations every 4 hours is not specifically required for clients on chlorpromazine. While respiratory depression can be a concern with some medications, it is not a common side effect of chlorpromazine.
Choice D reason: Administer an antacid with the medication to decrease nausea is not recommended. Antacids can interfere with the absorption of chlorpromazine, reducing its effectiveness. If the client experiences nausea, other antiemetic strategies should be considered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["100"]
Explanation
Step 1: Determine the total volume to be infused.
- Total volume = 50 mL
- Result: 50 mL
Step 2: Determine the total time for infusion in hours.
- Total time = 30 minutes
- Convert minutes to hours: 30 minutes ÷ 60 minutes/hour = 0.5 hours
- Result: 0.5 hours
Step 3: Calculate the flow rate in mL/hr.
- Flow rate (mL/hr) = Total volume (mL) ÷ Total time (hours)
- Flow rate (mL/hr) = 50 mL ÷ 0.5 hours
- Result: 50 ÷ 0.5 = 100
Final Answer: The nurse should set the IV pump to deliver 100 mL/hr.
Correct Answer is B
Explanation
Choice A reason:
Saying “It doesn’t appear as though you are feeling anxious” is not an appropriate response. This statement invalidates the client’s feelings and can make them feel misunderstood or dismissed. It is important for the nurse to acknowledge the client’s report of anxiety and provide a supportive environment for them to express their concerns.
Choice B reason:
“Tell me what has been happening lately” is the most appropriate response. This open-ended question encourages the client to share more about their experiences and feelings, which can help the nurse understand the underlying causes of the anxiety. It also shows empathy and a willingness to listen, which are crucial in building a therapeutic relationship.
Choice C reason:
“I think you should see a therapist” might be a helpful suggestion, but it is not the best immediate response. While referring the client to a therapist can be part of the long-term management plan, the nurse should first listen to the client’s concerns and provide immediate support. Suggesting therapy right away might make the client feel like their concerns are being brushed off.
Choice D reason:
“Do you think your anxiety is worse than everyone else’s?” is not a helpful response. This question can come across as judgmental and may make the client feel defensive or invalidated. It is important for the nurse to focus on understanding the client’s individual experience rather than comparing it to others.
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