A client with schizoaffective disorder is prescribed clozapine to treat her symptoms. Which of the following instructions would the nurse provide?

Correct Answer: C

Rationale: The correct answer is C because weight gain is a common side effect of clozapine. Monitoring weight is essential to catch any rapid weight gain, which could indicate potential metabolic issues. This instruction is crucial for the client's safety and well-being. A is incorrect because dry mouth is a common side effect of clozapine, but it is not typically necessary to keep a detailed record of the frequency and duration of this side effect. B is incorrect because changes in urine color are not typically associated with clozapine use. D is incorrect because experiencing drowsiness is a common side effect of clozapine and does not necessarily require discontinuation of the medication.

Correct Answer: C

Rationale: The correct answer is C: monitoring client treatment adherence. Nurses play a key role in ensuring patients comply with their treatment plans. This involves monitoring medication intake, therapy attendance, and following through with other recommended interventions. Nurses do not have the authority to prescribe medication (choice A) or perform surgical procedures (choice D). While some nurses may be trained in providing counseling, conducting psychotherapy sessions (choice B) is typically the role of licensed therapists or psychologists.

Correct Answer: C

Rationale: The correct answer is C because the statement reflects characteristics of the acute mourning stage, which includes intense emotions such as anger and sadness. The patient expressing anger towards God and crying all the time aligns with the typical reactions seen in the acute mourning stage. This stage is characterized by emotional outbursts and difficulty functioning in daily life. Choice A is incorrect because feeling guilty for not visiting the father and having trouble accepting the death are signs of denial, a stage that typically precedes acute mourning. Choice B is incorrect as it indicates acceptance and readiness to move on, which is not reflective of the acute mourning stage. Choice D is incorrect as it shows a focus on spending time with family and seeking support, which are more indicative of the later stages of mourning rather than the acute phase.

Correct Answer: C

Rationale: The correct answer is C because weight gain is a common side effect of clozapine. Monitoring weight is essential to catch any rapid weight gain, which could indicate potential metabolic issues. This instruction is crucial for the client's safety and well-being. A is incorrect because dry mouth is a common side effect of clozapine, but it is not typically necessary to keep a detailed record of the frequency and duration of this side effect. B is incorrect because changes in urine color are not typically associated with clozapine use. D is incorrect because experiencing drowsiness is a common side effect of clozapine and does not necessarily require discontinuation of the medication.

Correct Answer: B

Rationale: The correct answer is B: Cerebellum maturation. The cerebellum is responsible for emotional regulation and cognitive functions. As it matures during adolescence, individuals gain better emotional and behavioral control. Limited executive function (A) would hinder rather than improve control. Cerebral stasis and hormonal changes (C) do not directly contribute to emotional regulation. A slight reduction in brain volume (D) would not necessarily lead to increased emotional and behavioral control.

Correct Answer: A

Rationale: The correct answer is A because waving fists, cursing, and shouting threats indicate aggressive and confrontational behavior, which are common signs of a behavioral crisis. This behavior poses a potential threat to others and requires immediate intervention. In contrast, choices B and C show distress or withdrawal, not crisis-level behavior. Choice D depicts an unusual behavior but does not necessarily indicate a crisis. In summary, the correct answer best aligns with the aggressive and threatening behavior typically seen in a behavioral crisis.

Correct Answer: B

Rationale: The correct answer is B: Aggressive behavior signals. In forensic settings, early recognition of aggressive behavior signals is crucial for preventing potential harm. The nurse and client would focus on identifying triggers, developing coping strategies, and establishing safety plans. This approach aligns with the proactive nature of forensic nursing to prevent escalation of violence. Choices A, C, and D are incorrect because medication side effects, informed consent violations, and discharge needs are important but not directly related to early recognition of potential violence in forensic settings.

Correct Answer: D

Rationale: The correct answer is D (08:00). Lithium blood levels are typically drawn 12 hours after the last dose to ensure accuracy. Since the nurse administered the dose at 8 PM, the blood level should be checked at 8 AM the next day for accurate monitoring and adjustment of the dosage. Option A (22:00) is too soon after administration, option B (00:00) is not 12 hours after administration, and option C (04:00) is also not 12 hours after administration. Therefore, option D is the most appropriate time for obtaining a lithium blood level.

Correct Answer: D

Rationale: The correct answer is D: Social skills training. This is the most effective intervention for a child engaging in bullying because it directly addresses the underlying behavior by teaching appropriate social behaviors and communication skills. Social skills training can help the child understand the impact of their actions, develop empathy, and learn how to interact positively with others. A: Psychoeducation may provide information about bullying but does not necessarily teach the child new skills to change their behavior. B: Bibliotherapy involves reading books to promote understanding, which may not be as effective as directly teaching social skills. C: Early intervention programs are important, but social skills training specifically targets the behavior of bullying and provides practical strategies for change.