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The nurse is caring for a client who has been taking clozapine (Clozaril) for 2 weeks. The client tells the nurse, My throat is sore, and I feel weak. The nurse assesses the client?s vital signs and finds that the client has a fever. The nurse notifies the physician, expecting an order to obtain which laboratory test?
- A. A white blood cell count
- B. Liver function studies
- C. Serum potassium level
- D. Serum sodium level
Correct Answer: A
Rationale: Clozapine (A) carries a risk of agranulocytosis, a potentially life-threatening drop in white blood cells, presenting with symptoms like sore throat, weakness, and fever. Monitoring white blood cell counts is critical. Liver function (B), potassium (C), and sodium (D) levels are less relevant to these symptoms.
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A nurse is providing care to a client just recently diagnosed with schizophrenia during an inpatient hospital stay. Throughout the day, the nurse observes the client drinking from the water fountain quite frequently as well as carrying cans of soda and bottles of water with him wherever he goes. Upon entering the client?s room, the nurse sees numerous empty cups that had been filled with fluids on his table and in the trash can. The room has an odor of urine. The nurse suspects which of the following?
- A. Diabetes mellitus
- B. Disordered water balance
- C. Tardive dyskinesia
- D. Orthostatic hypotension
Correct Answer: B
Rationale: Excessive fluid intake and urine odor suggest disordered water balance (B), such as psychogenic polydipsia, common in schizophrenia, leading to excessive drinking and urination. Diabetes mellitus (A) may cause thirst but not typically urine odor in this context. Tardive dyskinesia (C) and orthostatic hypotension (D) are unrelated to these symptoms.
After assessing a client with schizophrenia, the nurse suspects that the client is experiencing an anticholinergic crisis. Which of the following would the nurse most likely have assessed? Select all that apply.
- A. Dilated reactive pupils
- B. Blurred vision
- C. Ataxia
- D. Coherent speech
- E. Facial pallor
- F. Disorientation
Correct Answer: B,C,F
Rationale: Anticholinergic crisis symptoms include blurred vision (B), ataxia (C), and disorientation (F) due to excessive anticholinergic effects (e.g., from medications). Dilated pupils (A) may occur but are less specific, coherent speech (D) is unlikely, and facial pallor (E) is not typical.
A nurse is preparing an in-service program for a group of psychiatric-mental health nurses about schizophrenia. Which of the following would the nurse include as a major reason for relapse?
- A. Lack of family support
- B. Accessibility to community resources
- C. Non-adherence to prescribed medications
- D. Stigmatization of mental illness
Correct Answer: C
Rationale: Non-adherence to prescribed medications (C) is a primary cause of relapse in schizophrenia, as antipsychotics are critical for symptom control. Lack of family support (A) and stigmatization (D) contribute indirectly, while accessibility to resources (B) is a protective factor.
While interviewing a client diagnosed with a delusional disorder, the client states, I have this really strange odor coming out of my mouth. I stop to brush my teeth almost every hour and then rinse with mouthwash every half hour to get rid of this smell. I?ve seen so many doctors, and they can?t tell me what?s wrong. The nurse interprets the client?s statement as reflecting which type of delusion?
- A. Erotomanic
- B. Grandiose
- C. Somatic
- D. Jealous
Correct Answer: C
Rationale: The client?s belief in a persistent, unexplained mouth odor reflects a somatic delusion (C), focusing on bodily concerns. Erotomanic (A) involves romantic beliefs, grandiose (B) involves inflated self-worth, and jealous (D) involves infidelity, none of which apply.
As part of an interdisciplinary team, a nurse is assisting in developing the plan of care for a client with a delusional disorder. Which of the following would the team be least likely to include in the plan?
- A. Insight-oriented therapy
- B. Psychoeducation
- C. Cognitive therapy
- D. Support therapy
Correct Answer: A
Rationale: Insight-oriented therapy (A) is least likely for delusional disorder, as clients often lack insight into their delusions, making this approach less effective. Psychoeducation (B), cognitive therapy (C), and support therapy (D) are more practical for managing symptoms and coping.