The nurse is continuing to care for the client.

Exhibits

A nurse is evaluating the client's response to therapy. Which of the following recent findings indicate the client's condition has improved or not changed?
For each assessment finding, click to specify if the finding indicates that the client's condition has improved or has not changed.

Rationale for Correct Choices:

• Right forearm and fingers are edematous: Swelling after trauma can indicate a fracture, severe soft tissue injury, or early compartment syndrome. Prompt assessment and imaging are necessary to prevent complications such as impaired circulation or permanent tissue damage.

• Fingers slightly cool to touch: Cool fingers suggest compromised blood flow, possibly due to vascular injury or compartment syndrome. Immediate evaluation is critical to restore perfusion and prevent ischemic injury.

• Child can move fingers and reports a mild "tingling" sensation: Paresthesia signals potential nerve compression or early compartment syndrome. Timely intervention can prevent permanent nerve damage or loss of function.

• Multiple areas of bruising are noted on lower extremities in various stages of healing: Bruises in different stages of healing may indicate non-accidental trauma. This finding requires urgent reporting and investigation according to child protection policies.

Rationale for Findings Not Requiring Immediate Follow-Up

• Respirations easy and unlabored: Normal respiratory effort indicates that airway and oxygenation are adequate, so no immediate intervention is required.

• Abdomen non-distended: A soft, non-distended abdomen suggests no acute abdominal injury or internal bleeding, reducing the urgency of intervention.

• Ecchymotic area noted on outer aspect of the forearm: Localized bruising is consistent with the reported fall and mild trauma; it does not indicate immediate threat to circulation or nerve function.

• Child verbalizes a pain level of 4 on a scale of 0 to 10: Moderate pain is expected after minor trauma and can be managed with standard analgesics; it does not indicate an emergent complication.

Rationale:
A. Sore throat: A sore throat can indicate agranulocytosis, a potentially life-threatening adverse effect of clozapine. Prompt monitoring of WBC counts and reporting symptoms such as fever or sore throat is essential to prevent serious infection.

B. Tinnitus: Tinnitus is not a common or severe adverse effect of clozapine. While it may be bothersome, it does not require immediate reporting to the provider in the context of clozapine therapy.

C. Rhinitis: Mild nasal congestion or rhinitis can occur with clozapine use but is generally not dangerous or indicative of a serious complication. Monitoring is routine, but urgent reporting is not required.

D. Headache: Headaches are a common, nonspecific side effect and do not typically indicate a life-threatening reaction. Routine assessment and symptom management are appropriate.