A nurse is reviewing laboratory results of a client who has schizophrenia and is taking risperidone. For which of the following findings should the nurse notify the provider?
Blood glucose 256 mg/dL (74 to 106 mg/dL)
WBC count 6,000/mm³ (5,000 to 10,000/mm³)
Platelets 250,000/mm³ (150,000 to 400,000/mm³)
Sodium 140 mEq/L (136 to 145 mEq/L)
The Correct Answer is A
Choice A reason: A blood glucose level of 256 mg/dL is significantly higher than the normal range and could indicate hyperglycemia, which is a serious side effect of risperidone. The provider should be notified immediately to manage this potential complication.
Choice B reason: A WBC count of 6,000/mm³ is within the normal range and does not typically warrant concern or the need to notify the provider.
Choice C reason: A platelet count of 250,000/mm³ is also within the normal range and is not indicative of an adverse reaction to risperidone.
Choice D reason: A sodium level of 140 mEq/L falls within the normal range and is not a cause for alarm in the context of risperidone therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Identifying the client's current stage of grief is crucial as it helps tailor the intervention to the client's specific needs. Understanding where the client is in the grieving process allows the nurse to provide appropriate emotional support and resources. It's the foundational step in managing complicated grief, as interventions may vary greatly depending on whether the client is in denial, anger, bargaining, depression, or acceptance.
Choice B reason: While physical activity can be beneficial for overall health and may help in managing symptoms of depression associated with grief, it is not the immediate priority. The nurse must first understand the client's emotional state before suggesting specific activities.
Choice C reason: Discussing the use of a spiritual grief counselor can be a valuable part of the healing process for some clients. However, this should come after assessing the client's beliefs and willingness to engage in spiritual counseling. It is not the first step in the care plan.
Choice D reason: Informing the client that feelings of anger are expected is part of educating the client about the grieving process. While it's important to normalize the range of emotions experienced during grief, it is more of a supportive intervention rather than a priority action.
Correct Answer is B
Explanation
Choice A reason: Assisting the client to use new coping strategies is an important part of managing bipolar disorder, but it is not the first action a nurse should take when establishing a nurse-client relationship. Coping strategies will be more effective once a trusting relationship has been established and the client feels secure in sharing personal information.
Choice B reason: Establishing confidentiality guidelines with the client is the first and most crucial step in forming a therapeutic nurse-client relationship. It sets the foundation for trust and openness, ensuring the client understands that their personal information will be protected and shared only with those directly involved in their care.
Choice C reason: Helping the client to make behavioral changes is a goal in the treatment of bipolar disorder. However, before any interventions can be planned or implemented, the nurse must first establish a rapport and trust with the client, which begins with ensuring confidentiality.
Choice D reason: Sharing information with the client about their disorder is essential for their understanding and participation in care. However, this should occur after establishing a relationship in which the client feels comfortable and secure, knowing their privacy is respected.
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