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.

Answer and Explanation

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.

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Correct Answer is D

No explanation

A. Bowel sounds. B. Blood pressure. C. Oxygen saturation. D. Pupil response.

Correct Answer is B

Explanation

The correct answer is Choice b, Blood pressure.

Rationale for Choice a, Bowel sounds:

Bowel sounds are not directly relevant to the potential interaction between phenelzine and pepperoni pizza.
While assessing bowel sounds is a part of a comprehensive nursing assessment,it would not be the top priority in this specific scenario.
Phenelzine does not typically cause gastrointestinal disturbances that would warrant immediate assessment of bowel sounds.

Rationale for Choice c, Oxygen saturation:

Oxygen saturation is not directly affected by the interaction between phenelzine and pepperoni pizza.
Assessing oxygen saturation would be more pertinent in situations involving respiratory distress or hypoxia.
There is no evidence to suggest that this interaction would cause respiratory depression or compromise oxygen saturation levels.

Rationale for Choice d, Pupil response:

Pupil response is not a reliable indicator of the potential complications associated with phenelzine and tyramine-rich foods.
It's primarily assessed for neurological conditions or drug intoxication affecting the central nervous system.
The interaction between phenelzine and tyramine primarily affects the cardiovascular system,not the neurological system.

Rationale for Choice b, Blood pressure:

Blood pressure is the most critical assessment in this scenario due to the potential for a hypertensive crisis.
Phenelzine is a monoamine oxidase inhibitor (MAOI),which blocks the breakdown of tyramine,a substance found in certain foods like pepperoni,aged cheeses,and fermented products.
When tyramine levels increase,it can trigger a sudden and severe rise in blood pressure,known as a hypertensive crisis.
Symptoms of a hypertensive crisis can include:
- Severe headache
- Neck stiffness
- Chest pain
- Nausea
- Vomiting
- Blurred vision
- Sweating
- Photophobia (sensitivity to light)
- Palpitations
- Anxiety
- Confusion
- Seizures
- Stroke
- Potentially death
Prompt assessment of blood pressure is crucial for early detection and intervention to prevent these life-threatening complications.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an in-patient facility is caring for a client who has an anxiety disorder. Which of the following actions should the nurse take while the client is experiencing an acute panic attack?

Correct Answer is D

A nurse is assessing a client who has depression and takes phenelzine. The client reports eating pepperoni pizza while out on a pass during lunchtime. Which of the following assessments should the nurse perform?

Correct Answer is B

Explanation

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