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 C
Explanation
The correct answer is choice c. WBC count 13,000/mm².
Choice A rationale:
A BUN (Blood Urea Nitrogen) level of 16 mg/dL is within the normal range (7-20 mg/dL) and does not indicate an increased risk for delirium.
Choice B rationale:
Neuropathy, while a significant condition, is not directly associated with an increased risk of delirium. Delirium is more commonly linked to acute changes in health status.
Choice C rationale:
An elevated WBC count of 13,000/mm² indicates an infection or inflammation, which can increase the risk of delirium, especially in older adults or those with compromised health.
Choice D rationale:
Hypertension is a chronic condition that does not directly increase the risk of delirium. Delirium is more often associated with acute medical conditions or changes.
Correct Answer is D
No explanation
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