Dietary intake
Sore throat
Heart rate
Blood pressure
The Correct Answer is B
Rationale:
A. Dietary intake: The client ate 75% of breakfast, which indicates adequate oral intake. While monitoring nutrition is important in schizophrenia, this finding does not pose an immediate safety concern or require urgent reporting.
B. Sore throat: A sore throat in a client taking clozapine is significant because clozapine can cause agranulocytosis, a potentially life-threatening reduction in white blood cells. Any signs of infection, such as sore throat or fever, must be reported immediately to prevent serious complications.
C. Heart rate: A heart rate of 98/min is slightly elevated but within acceptable limits for many adults. This finding alone does not indicate an urgent issue requiring immediate provider notification.
D. Blood pressure: A blood pressure of 102/56 mm Hg is slightly low but may be within the client’s normal range, particularly if the client experiences dizziness when changing positions. While it should be monitored, it does not require urgent reporting unless symptoms worsen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. "Why did you start drinking alcohol?": This question explores motivations or personal history but is not part of the standardized Alcohol Use Disorders Identification Test (AUDIT). The AUDIT focuses on quantity, frequency, and consequences of alcohol use rather than reasons for drinking.
B. "Does anyone else in your family have a drinking problem?": Family history of alcohol use may be relevant for overall assessment but is not included in the AUDIT, which is designed to screen the client’s own drinking behaviors and risks.
C. "How old were you when you started to drink alcohol?": Age of initiation provides background information but is not a question within the AUDIT. The test is concerned with current patterns and consequences of alcohol consumption.
D. "How often do you drink alcohol?": This question is a standard component of the AUDIT and assesses the frequency of alcohol consumption. It helps identify patterns of use and potential risk for alcohol-related problems, making it appropriate for inclusion in the screening.
Correct Answer is C
Explanation
Rationale:
A. Instruct the client to discard the medication in the toilet: Disposing of medication in the toilet is not a recommended first action, as it does not address the client’s question about safely taking a half dose. Safe disposal is only necessary for expired or unwanted medications.
B. Manually break the tablets in half: Manually breaking tablets without knowing if they are designed to be split can lead to inaccurate dosing and affect drug efficacy. Some medications are not safe to split due to extended-release properties or uneven distribution of active ingredients.
C. Determine if the tablets are scored: Scored tablets are specifically designed to be split, ensuring accurate dosing. The nurse should verify whether the medication is scored before advising the client to cut it, ensuring safety and effectiveness of the prescribed dose.
D. Ask the pharmacy to create a liquid version of the medication: While a liquid formulation may be appropriate for accurate dosing if the tablet cannot be safely split, the first step is to confirm whether the current tablet can be divided. The pharmacy can then provide alternatives if splitting is unsafe.
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