Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
What is the priority finding to report to the provider for a client who has schizophrenia and is taking clozapine?
A. Sore throat
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.
B. Heart rate 104/min
C. Nausea
D. Random blood glucose 130 mg/dL
This question is an excerpt from Nurse Dive's nursing test bank - RN Mental Health 2019 With NGN Proctored Exam. Take the full exam now
Full Explanation
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.
Similar Questions
A nurse has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse take?
A. Obtain the provider's prescription within 60 min.
Obtaining the provider's prescription within 60 min is not the immediate action required in this scenario. The priority is to ensure the safety of the client and others, which is achieved by continuous monitoring and documentation.
B. Document the client's behavior every 15 min.
Documenting the client's behavior every 15 min is crucial in managing physically aggressive clients in seclusion. This allows the healthcare team to monitor the client's condition closely and make necessary interventions promptly.
C. Monitor the client's vital signs every 4 hr.
Monitoring the client's vital signs every 4 hr may not be frequent enough for a client in seclusion who has been physically aggressive. The client's condition could change rapidly, and more frequent monitoring might be necessary.
D. Offer the client food and fluids every 2 hr.
Offering food and fluids every 2 hr is important for maintaining the client's physical health, but it is not the primary action in managing a physically aggressive client in seclusion. The immediate focus should be on ensuring safety and managing the client's aggressive behavior.
Full Explanation
Choice A reason:
Obtaining the provider's prescription within 60 min is not the immediate action required in this scenario. The priority is to ensure the safety of the client and others, which is achieved by continuous monitoring and documentation.
Choice B reason:
Documenting the client's behavior every 15 min is crucial in managing physically aggressive clients in seclusion. This allows the healthcare team to monitor the client's condition closely and make necessary interventions promptly.
Choice C reason:
Monitoring the client's vital signs every 4 hr may not be frequent enough for a client in seclusion who has been physically aggressive. The client's condition could change rapidly, and more frequent monitoring might be necessary.
Choice D reason:
Offering food and fluids every 2 hr is important for maintaining the client's physical health, but it is not the primary action in managing a physically aggressive client in seclusion. The immediate focus should be on ensuring safety and managing the client's aggressive behavior.
A charge nurse is educating a newly licensed nurse about various defense mechanisms. Which of the following examples should the charge nurse provide when discussing rationalization?
A. A client who has stomach pain before presenting a project to his coworkers.
B. A client whose partner died 5 years ago still talks about him in the present tense.
C. A client who states she will worry about her grades after she finishes planning a party.
D. A client who states she did not get a promotion because her boss dislikes her.
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.
Full 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.
A home health nurse visits a client who lost their partner 2 years ago. Which of the following behaviors by the client indicates a maladaptive grief response?
A. The client gives away some of the partner's belongings.
B. The client expresses feelings of guilt.
C. The client relocates from a house to an apartment.
D. The client is unable to perform basic hygiene tasks.
A maladaptive grief response is one that interferes with normal functioning or causes significant distress for the bereaved person. The client who is unable to perform basic hygiene tasks is showing signs of depression and impaired self-care, which indicate a maladaptive grief response. The other behaviors are not necessarily maladaptive, but may reflect normal coping strategies or adjustments after losing a partner.
Full Explanation
A maladaptive grief response is one that interferes with normal functioning or causes significant distress for the bereaved person. The client who is unable to perform basic hygiene tasks is showing signs of depression and impaired self-care, which indicate a maladaptive grief response. The other behaviors are not necessarily maladaptive, but may reflect normal coping strategies or adjustments after losing a partner.