Nokea
When the client calls the nurse to report the following physical changes, which symptom is considered a serious side effect of clozapine that needs to be reported immediately to the prescribing physician?
- A. Frequent diarrhea
- B. Severe sore throat
- C. Gradual weight loss
- D. Ringing of the ears
Correct Answer: B
Rationale: Severe sore throat may indicate agranulocytosis, a life-threatening side effect of clozapine.
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Of the following suggestions, which one would best prevent nursing personnel from becoming injured when providing the adolescent with care?
- A. Apply soft wrist restraints before ambulating the client.
- B. Ask a parent to care for the client.
- C. Explain steps involved in care before touching the client.
- D. Medicate the client immediately before ambulation.
Correct Answer: C
Rationale: Explaining steps reduces fear and potential for aggressive reactions.
Which statement is the best explanation for the adolescent's behavior?
- A. Aggression is a common behavior manifested by cognitively disabled people.
- B. Aggression is a response that occurs when a person feels frustrated or frightened.
- C. Aggression is an indication that the client has a poor opinion of the care provided.
- D. Aggression is a common way for adolescents to communicate they are experiencing pain.
Correct Answer: B
Rationale: Frustration or fear often triggers aggression in cognitively disabled individuals.
To ensure optimum mental health of an infant born with a congenital defect such as myelomeningocele, the nurse explains that it is essential for the parents to meet which of the following needs?
- A. Autonomy
- B. Love
- C. Respect
- D. Identity
Correct Answer: B
Rationale: Love and attachment are critical for the infant's emotional and mental health development.
Which nursing action is most appropriate at this time?
- A. Postpone weighing the client until later.
- B. Confront the client about the water intake.
- C. Say nothing and weigh the client as usual.
- D. Subtract 2 lb (0.9 kg) from the client's weight.
Correct Answer: A
Rationale: Postponing weighing ensures accuracy and addresses manipulative behavior.
Of the following community resources, which referral is the nurse most likely to suggest for this client?
- A. Alcoholics Anonymous
- B. Al-Anon
- C. Alateen
- D. The Substance Abuse Council
Correct Answer: C
Rationale: Alateen supports teens affected by a family member's alcoholism.