A patient with schizophrenia shows suicidal behaviors, and the provider orders clozapine [Clozaril]. The nurse teaches the family about the medication and its side effects
Which state-ment by a family member indicates a need for further teaching about this drug? a. "Blood counts are necessary for several weeks after discontinuation of the drug."
b. "Fever, sore throat, and sores in the mouth should be reported immediately."
c. "If the ANC is less than 3000, the drug will be discontinued permanently."
d. "Use of this drug requires weekly evalua-tion of blood work."
C
Clozapine can cause agranulocytosis. If the absolute neutrophil count (ANC) drops below 1000/mcL, the drug must be discontinued permanently. Blood counts must be evaluated weekly, and this evaluation should be continued for several weeks after withdrawal of the drug. Fever, sore throat, and mouth ulcers are symptoms of agranulocytosis and should be reported imme-diately.
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A nurse cares for a male client with hypopituitarism who is prescribed testosterone hormone replacement therapy. The client asks, "How long will I need to take this medication?" How should the nurse respond?
a. "When your blood levels of testosterone are normal, the therapy is no longer needed." b. "When your beard thickens and your voice deepens, the dose is decreased, but treatment will continue forever." c. "When your sperm count is high enough to demonstrate fertility, you will no longer need this therapy." d. "With age, testosterone levels naturally decrease, so the medication can be stopped when you are 50 years old."
The patient expresses a desire to learn methods to be independent regarding self-care. Based on this, the most appropriate nursing diagnosis would be:
a. ineffective health maintenance. b. readiness for enhanced self-care. c. hygiene self-care deficit. d. disturbed body image.
A client is receiving enalapril for treatment of heart failure. Which of the following assessment findings should the nurse be concerned about following the initial administration of this drug?
1. Ototoxicity 2. Serious rash 3. Low blood pressure 4. Irregular pulse
A nurse is evaluating a client for commencement of enteral feedings. The most appropriate client to receive enteral feeding is the client who has _____ bowel sounds
a. decreased b. absent c. intact d. occasional