Nokea
A client with schizophrenia is being treated with clozapine (Clozaril). What is the most important laboratory test for the LPN/LVN to monitor?
- A. White blood cell count.
- B. Liver function tests.
- C. Blood glucose levels.
- D. Platelet count.
Correct Answer: A
Rationale: The most important laboratory test for an LPN/LVN to monitor for a client with schizophrenia being treated with clozapine is the white blood cell count. Clozapine treatment is associated with a risk of agranulocytosis, a severe drop in white blood cells, which can be life-threatening. Monitoring the white blood cell count regularly helps to detect this adverse effect early. Liver function tests (Choice B) are important to monitor with some antipsychotic medications but are not the most crucial for clozapine. Blood glucose levels (Choice C) are more relevant for monitoring in clients on medications like atypical antipsychotics that can cause metabolic side effects. Platelet count (Choice D) is not typically affected by clozapine therapy and is not the most important test to monitor in this case.
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The RN is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (select one that does not apply)
- A. Purchase a gun to use for protection.
- B. Keep quiet and calm.
- C. Take a self-defense course that retaliates against the abuser with injury.
- D. Have a bag ready that has extra clothes for self and children.
Correct Answer: C
Rationale: Taking a self-defense course that retaliates against the abuser with injury can escalate the level of violence and is not recommended in a safety plan for a victim of intimate partner violence. The correct strategies include establishing a code, having a bag ready, and planning an escape route, which enhance safety without increasing the risk of harm.
The charge nurse is collaborating with the nursing staff about the plan of care for a client who is very depressed. What is the most important intervention to implement during the first 48 hours after the client's admission to the unit?
- A. Monitor appetite and observe intake during meals.
- B. Maintain safety in the client's environment.
- C. Provide ongoing, supportive contact.
- D. Encourage participation in activities.
Correct Answer: B
Rationale: The most critical intervention to implement during the first 48 hours after admitting a depressed client is to maintain safety (B). Depression increases the risk of suicide; hence ensuring a safe environment is the priority. While monitoring appetite (A), providing supportive contact (C), and encouraging participation in activities (D) are important aspects of care for a depressed client, ensuring safety takes precedence in the initial phase of admission.
A client with Alzheimer's disease is becoming increasingly agitated and combative in the late afternoon. What is the most appropriate intervention?
- A. Offer a sedative medication to calm the client.
- B. Encourage the client to rest in a quiet, low-stimulation environment.
- C. Use reality orientation to reduce confusion.
- D. Engage the client in physical activity to reduce agitation.
Correct Answer: B
Rationale: Encouraging the client to rest in a quiet, low-stimulation environment is the most appropriate intervention for a client with Alzheimer's disease who is becoming agitated and combative in the late afternoon. This approach helps reduce agitation and prevent overstimulation, providing a calming and soothing environment for the client. Offering a sedative medication (Choice A) should be avoided as it may have side effects and should only be considered as a last resort. Reality orientation (Choice C) may increase confusion and distress in clients with advanced Alzheimer's disease. Engaging the client in physical activity (Choice D) could potentially escalate the agitation rather than reduce it in this scenario.
A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates her mannerisms. Which defense mechanism does the nurse recognize in this client?
- A. Sublimation.
- B. Identification.
- C. Introjection.
- D. Repression.
Correct Answer: B
Rationale: Identification is the correct answer. It is a defense mechanism where an individual unconsciously models themselves after someone they admire or feel close to. In this scenario, the client is imitating the nurse's mannerisms, indicating identification. Sublimation involves channeling unacceptable impulses into socially acceptable activities. Introjection is the internalization of external attitudes or voices, while repression involves suppressing unwanted thoughts or desires.
A nurse determines that the wife of an alcoholic client is benefitting from attending an Al-Anon group when the nurse hears the wife say:
- A. I no longer feel that I deserve the meetings my husband inflicts on me.
- B. My attendance at the meetings has helped me to see that I provoke my husband's violence.
- C. I enjoy attending the meetings because they get me out of the house and away from my husband.
- D. I can tolerate my husband's destructive behaviors now that I know they are common with alcoholics.
Correct Answer: A
Rationale: Choice A is the correct answer as the statement indicates the wife understands that her husband's behavior is not her fault and is benefitting from the group support. Choice B is incorrect as it suggests self-blame rather than recognizing the husband's responsibility. Choice C is incorrect as the benefit is related to emotional support and understanding, not just getting away from the husband. Choice D is incorrect as tolerating destructive behaviors is not a healthy outcome of attending support groups.