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 C
Explanation
Choice A reason: A productive cough
A productive cough is not typically associated with an acute hemolytic reaction. This symptom is more commonly related to respiratory conditions such as infections or chronic obstructive pulmonary disease (COPD). Acute hemolytic reactions primarily involve symptoms related to the destruction of red blood cells and the immune response.
Choice B reason: Distended neck veins
Distended neck veins are usually a sign of congestive heart failure or fluid overload. While they can indicate a serious condition, they are not specific to acute hemolytic reactions. The primary symptoms of an acute hemolytic reaction involve the immune system’s response to incompatible blood transfusion.
Choice C reason: Client report of low back pain
Low back pain is a classic symptom of an acute hemolytic reaction. This pain is typically due to the kidneys’ response to the breakdown of red blood cells, which can lead to hemoglobinuria and renal damage. The immune system’s attack on the transfused red blood cells causes this reaction, making it a critical symptom to recognize.
Choice D reason: Client report of tinnitus
Tinnitus, or ringing in the ears, is not associated with acute hemolytic reactions. This symptom is more commonly related to auditory issues or side effects of certain medications. Acute hemolytic reactions involve symptoms such as fever, chills, back pain, and hemoglobinuria.
Correct Answer is D
Explanation
Choice A reason: Intention tremors are not typically associated with Addison’s disease. Intention tremors are more commonly seen in conditions affecting the cerebellum, such as multiple sclerosis or cerebellar ataxia.
Choice B reason: Purple striations (striae) are more commonly associated with Cushing’s syndrome, which is characterized by excessive cortisol levels. Addison’s disease, on the other hand, involves insufficient cortisol production.
Choice C reason: Hirsutism refers to excessive hair growth in women in areas where hair is normally minimal or absent. This condition is more commonly associated with polycystic ovary syndrome (PCOS) or other endocrine disorders, not Addison’s disease.
Choice D reason: Hyperpigmentation is a hallmark sign of Addison’s disease. It occurs due to increased production of melanocyte-stimulating hormone (MSH) as a byproduct of elevated adrenocorticotropic hormone (ACTH) levels. This leads to darkening of the skin, especially in areas exposed to friction, such as the elbows, knees, knuckles, and scars.
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