What is the priority finding to report to the provider for a client who has schizophrenia and is taking clozapine?
Sore throat
Heart rate 104/min
Nausea
Random blood glucose 130 mg/dL
The Correct Answer is A
This finding could indicate agranulocytosis, a potentially life threatening adverse effect of clozapine that causes a severe decrease in white blood cells and increases the risk of infection. The other findings are also important to monitor, but they are not as critical as sore throat.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse's priority is to address the client's physical needs, such as nutrition and hydration, which are essential for survival and recovery. The client who is unable to eat more than once a day is at risk for malnutrition, dehydration, and electrolyte imbalance, which can lead to serious complications. The other findings indicate emotional distress and grief, which are also important to address, but not as urgent as the client's physical health.
Correct Answer is D
Explanation
Rationalization is a defense mechanism that involves making excuses or justifying one's behavior or failures. The client who blames their boss for not getting a promotion is using rationalization to avoid accepting responsibility or acknowledging their shortcomings. The other examples are not related to rationalization, but to other defense mechanisms, such as somatization, denial, and procrastination.
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