A nurse is reinforcing education to 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?
Severe restlessness
Respiratory depression and a comatose state
Sore throat and muscle aches
Increased anxiety and suicidal ideations
The Correct Answer is C
A. Severe restlessness. Severe restlessness, known as akathisia, is a potential side effect of antipsychotic medications but is not indicative of agranulocytosis. Akathisia is associated with excessive movement and an inability to stay still, often requiring dose adjustment or medication to alleviate symptoms.
B. Respiratory depression and a comatose state. Respiratory depression and coma are not linked to agranulocytosis but may occur with overdose or central nervous system depression. Agranulocytosis affects white blood cell levels, leading to increased infection risk rather than sedation or respiratory suppression.
C. Sore throat and muscle aches. Sore throat and muscle aches are early signs of agranulocytosis, a potentially life-threatening condition characterized by a dangerously low neutrophil count. Clients taking clozapine must undergo regular white blood cell monitoring to detect agranulocytosis early and prevent severe infections.
D. Increased anxiety and suicidal ideations. Increased anxiety and suicidal ideations may be related to psychiatric conditions or medication effects but are not specific to agranulocytosis. Clozapine is primarily used for treatment-resistant schizophrenia and may help reduce suicidal behavior rather than induce it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Being in a family with numerous siblings. While family dynamics can influence mental health, having multiple siblings does not inherently increase the risk for mental illness. Protective factors such as social support from siblings may actually be beneficial.
B. Early exposure to violence. Experiencing violence at a young age, such as abuse or witnessing traumatic events, can increase the risk for mental illness by altering stress responses, emotional regulation, and cognitive development.
C. Being raised by a single mother. While single-parent households may present challenges, they do not directly cause mental illness. Supportive parenting, economic stability, and social resources can mitigate potential stressors.
D. Living in a rural area. Although access to mental health care may be more limited in rural areas, residing in such an environment is not a direct risk factor for developing mental illness. Social support and lifestyle factors play a more significant role.
Correct Answer is C
Explanation
A. Although you have mentioned wanting to talk today about your past abuse, let's discuss this handout I have with new coping skills. Redirecting the client away from their chosen topic disregards their needs and autonomy. Patient-centered care involves respecting the client’s concerns and prioritizing what is most meaningful to them.
B. I am going to have to change our meeting time because I need to go get lunch. Changing the meeting time based on the nurse’s personal needs rather than the client’s schedule does not align with patient-centered care. The focus should remain on the client's well-being and therapeutic relationship.
C. Let's review the goals you set today and see what your priority is this week. Reviewing client-established goals and prioritizing their needs aligns with patient-centered care. This approach fosters collaboration and empowers the client to take an active role in their recovery.
D. I would like to focus on what I believe are the best goals for you to work on. Imposing the nurse’s priorities over the client’s goals does not support patient-centered care. Instead, care should be tailored to the client's preferences, values, and recovery journey.
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