Nokea
The client is being treated with Clozapine. Which findings during the nurse's assessment indicate that the client is experiencing adverse effects of Clozapine? Select all that apply.
- A. Dehydration
- B. Agranulocytosis
- C. Increasing anxiety
- D. Extreme salivation
- E. Blood glucose 192 mg/dL
Correct Answer: B,D,E
Rationale: Agranulocytosis, hypersalivation, and hyperglycemia are adverse effects of clozapine (Clozaril).
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The client taking tranylcypromine develops a list of possible meal plans. Which meal plans should the nurse identify as safe for the client? Select all that apply.
- A. Pepperoni pizza, Caesar salad, 16 oz iced tea
- B. Grilled pork loin, rice, green beans, 12 oz diet clear soda
- C. Grilled salmon, steamed broccoli, 12 oz lemon-lime soda
- D. Baked chicken, mashed potatoes and gravy, 8 oz 2% milk
- E. Granola with raisins and almonds, low-fat yogurt, and 8 oz coffee
- F. Beef burritos with sour cream and guacamole topping, corn chips, 12 oz beer
Correct Answer: B,C,D
Rationale: Meals without tyramine (e.g., pepperoni, raisins, yogurt, sour cream, avocados, beer) are safe for clients taking MAOIs like tranylcypromine.
What is pica?
- A. dependency on alcohol
- B. increased iron in the diet
- C. the sickle cell trait
- D. eating ice
Correct Answer: D
Rationale: Pica represents the ingestion of nonfood substances that leads to a clinical iron deficiency and might actually be the first sign of a problem. Clients eat a wide range of nonfood items, including ice, clay, dirt, and paste.
The nurse is receiving a report from an ER nurse about a client. Which of the following statements requires additional follow-up?
- A. The client said they have been taking aspirin, but I'm not sure for how long or how much.
- B. The client frequently takes antacids, but they have not taken any in the last three days.
- C. The client stopped taking ibuprofen after developing gastric ulcers.
- D. The client takes Antabuse and has stopped using mouthwash.
Correct Answer: A
Rationale: Aspirin can have an impact on the patient's bleeding risk, so the amount and frequency is important to know. Antacids can change the gastric pH and impact medication absorption, so the nurse should note when they are last taken. Ibuprofen can cause or exacerbate gastric ulcers. Clients who take Antabuse should avoid alcohol in all forms, including avoiding over-the-counter cough medication and mouthwash.
The nurse is developing the plan of care for the 7-year-old with encopresis who has been started on lactulose. Which outcome would be most appropriate for the nurse to establish?
- A. 2-pound weight gain
- B. Nighttime continence
- C. Blood glucose 70-110 mg/dL
- D. Normal bowel movement daily
Correct Answer: D
Rationale: A: Weight gain is not expected with an osmotic laxative. B: Nighttime continence is not expected to be altered by an osmotic laxative. C: Blood glucose is not expected to be altered by an osmotic laxative. D: Lactulose (Constulose) is an osmotic laxative used in treating encopresis to prevent constipation; the nurse should establish an outcome of a normal daily bowel movement.
The nurse is performing a health history on the child with ADHD who is being evaluated for treatment with psychostimulants. Which information is most critical to collect prior to treatment with psychostimulants?
- A. Musculoskeletal history
- B. Genitourinary history
- C. Immunization history
- D. Cardiovascular history
Correct Answer: D
Rationale: Cardiovascular history is critical due to contraindications of psychostimulants in certain CV conditions.