A nurse is educating a client who is prescribed clozapine.

Which of the following findings should the nurse identify as consistent with agranulocytosis and instruct the client to monitor?

Respiratory depression and a comatose state.

Sore throat and muscle aches.

Increased anxiety and suicidal ideations.

Severe restlessness.

Answer and Explanation

The Correct Answer is B

Choice A rationale:
Respiratory depression and a comatose state are not typically associated with agranulocytosis.
Choice B rationale:
Agranulocytosis, a potential side effect of clozapine, can cause symptoms like a sore throat and muscle aches due to the body’s decreased ability to fight off infections.
Choice C rationale:
Increased anxiety and suicidal ideations are not typically symptoms of agranulocytosis.
Choice D rationale:
Severe restlessness is not a common symptom of agranulocytosis.

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Correct Answer is D

Explanation

Choice A rationale:
Asking direct questions about the hallucination may validate the hallucination as real in the client’s mind.
Choice B rationale:
Instructing the client to argue with the voices could potentially increase the client’s distress.
Choice C rationale:
Acting as if the hallucination is real may reinforce the client’s belief in the hallucination.
Choice D rationale:
Telling the client that the hallucination is not a part of reality can help ground the client in reality.

A. "I know you hear the voices, but I do not.”. B. "The voices are part of your illness.”. C. "How often do you hear the voices?". D. "What are the voices telling you?".

Correct Answer is D

Explanation

Choice A rationale:

While acknowledging the voices can be part of therapeutic communication, it’s not the first response a nurse should make.

Choice B rationale:

Telling the client that the voices are part of their illness can be helpful, but it’s not the first response a nurse should make.

Choice C rationale:

Asking about the frequency of the voices can be part of the assessment, but it’s not the first response a nurse should make.

Choice D rationale:

Asking what the voices are saying can help assess if the client is experiencing command hallucinations, which could pose a safety risk.

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A nurse is educating a client who is prescribed clozapine. Which of the following findings should the nurse identify as consistent with agranulocytosis and instruct the client to monitor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has schizophrenia and is experiencing a hallucination. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following responses should the nurse make first?

Correct Answer is D

Explanation

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A nurse is educating a client who is prescribed clozapine.

Which of the following findings should the nurse identify as consistent with agranulocytosis and instruct the client to monitor?