The nurse is caring for a client with schizoaffective disorder and type 2 diabetes mellitus who receives a prescription for a second generation antipsychotic. The client expresses concern to the nurse about the effect of this antipsychotic on blood glucose levels. Which response should the nurse make?
"This medication may cause watery eyes and diarrhea. These will go away within 2 weeks."
"Side effects are not likely with this type of medication. There should be no need to worry."
"I can provide an education sheet with your discharge papers. What is your primary language?"
"This type of medication is generally well tolerated. Tell me more about your concerns."
The Correct Answer is D
Choice A rationale: The nurse's response regarding watery eyes and diarrhea is not directly related to the client's concern about the medication's effect on blood glucose levels.
Choice B rationale: This response minimizes the potential side effects, which is not accurate. Second-generation antipsychotics are associated with metabolic side effects, including changes in blood glucose levels.
Choice C rationale: Offering an education sheet is helpful but does not directly address the client's specific concerns about the medication's impact on blood glucose levels.
Choice D rationale: This response acknowledges the client's concern, provides information about the general tolerability of the medication, and invites the client to share more about their specific worries. It encourages open communication and allows the nurse to address the client's concerns more effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Providing teaching on the symptoms of substance use dependence may be appropriate, but supporting the client's desire for positive changes is the immediate priority.
Choice B rationale: Advising the client to reschedule is not supportive of their current motivation for change.
Choice C rationale: Supporting the client to list small behavioral changes needed aligns with the client's expressed desire for a healthier lifestyle and is consistent with motivational interviewing techniques.
Choice D rationale: Explaining specific relapse prevention skills may be useful later in the recovery process, but initially supporting the client's motivation for change is the priority.
Correct Answer is B
Explanation
Choice A rationale: Hydrochlorothiazide is a diuretic and may contribute to electrolyte imbalances, but it is not the most concerning medication in this situation. Choice B rationale: Phenelzine is a monoamine oxidase inhibitor (MAOI), and the combination of an MAOI with certain foods or medications containing tyramine can lead
to a hypertensive crisis. The client's elevated blood pressure is of concern, and the nurse should notify the healthcare provider.
Choice C rationale: Losartan is an angiotensin II receptor blocker (ARB) used to treat hypertension. While it may contribute to blood pressure control, it is not the most concerning medication in this scenario.
Choice D rationale: Aspirin, at a dose of 81 milligrams, is often used for cardiovascular prophylaxis and is not the most concerning medication in this situation.
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