A nurse is caring for a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to report to the provider?
Random blood glucose 130 mg/dL.
Heart rate 104/min.
Nausea
Sore throat.
The Correct Answer is D
The correct answer is choice d. Sore throat. Choice A rationale: A random blood glucose level of 130 mg/dL is slightly elevated but not immediately concerning. It should be monitored, especially since clozapine can cause metabolic changes, but it is not the priority. Choice B rationale: A heart rate of 104/min is slightly elevated and could be a side effect of clozapine, which can cause tachycardia. However, it is not as urgent as other potential side effects. Choice C rationale: Nausea is a common side effect of many medications, including clozapine. While uncomfortable, it is not typically a priority concern unless it leads to severe dehydration or other complications. Choice D rationale: A sore throat can be a sign of agranulocytosis, a potentially life-threatening condition where the white blood cell count drops dangerously low. Clozapine is known to cause this condition, and it requires immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A, displacement.
Rationale for Choice A, displacement:
- Definition of displacement:Displacement is a defense mechanism in which a person redirects their emotions or impulses from the original target to a less threatening one.It's a way of coping with anxiety or frustration by channeling those feelings onto a safer object or person.
- Evidence in the scenario:The client is angry with his partner,but instead of expressing that anger directly to her,he redirects it towards the nurse.This suggests that he finds it safer to express his anger towards the nurse,who is less likely to retaliate or reject him,than towards his partner.
Rationale for other choices:
- Choice B, rationalization:Rationalization involves justifying one's actions or thoughts with excuses or explanations that make them seem more acceptable.There's no evidence in the scenario that the client is trying to justify his anger or provide excuses for it.
- Choice C, denial:Denial involves refusing to acknowledge or accept a painful reality.The client isn't denying his anger; he's openly expressing it.However,he's directing it towards the nurse instead of his partner.
- Choice D, compensation:Compensation involves trying to make up for a perceived weakness or inadequacy by emphasizing a different strength or ability.There's no indication in the scenario that the client is trying to compensate for anything.
Further considerations:
- It's important to note that defense mechanisms are often unconscious,meaning the person using them isn't aware of what they're doing.This can make them difficult to identify and address.
- In this case,the nurse could try to help the client become more aware of his anger and how he's expressing it.They could also encourage him to explore healthier ways of coping with his feelings,such as talking to his partner directly or seeking professional help.
Correct Answer is A
No explanation
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