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A nurse is caring for a client who has schizophrenia in an inpatient facility. Exhibit 1 Medication Administration Record 0730: Clozapine 100 mg PO daily Aripiprazole 5 mg PO daily Multivitamin PO daily Exhibit 2 Laboratory Results 0730: Sodium 125 mEq/L (136 to 145 mEq/L) Potassium 3.5 mEq/L (3.5 to 5.0 mEq/L) Chloride 90 mEq/L (98 to 106 mEq/L) BUN 8 mg/dL (10 to 20 mg

A nurse is caring for a client who has schizophrenia in an inpatient facility. Exhibit 1 Medication Administration Record 0730: Clozapine 100 mg PO daily Aripiprazole 5 mg PO daily Multivitamin PO daily Exhibit 2 Laboratory Results 0730: Sodium 125 mEq/L (136 to 145 mEq/L) Potassium 3.5 mEq/L (3.5 to 5.0 mEq/L) Chloride 90 mEq/L (98 to 106 mEq/L) BUN 8 mg/dL (10 to 20 mg

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A nurse is caring for a client who has schizophrenia in an inpatient facility.

Exhibit 1

Medication Administration Record

0730:

Clozapine 100 mg PO daily

Aripiprazole 5 mg PO daily

Multivitamin PO daily

Exhibit 2

Laboratory Results

0730:

Sodium 125 mEq/L (136 to 145 mEq/L)

Potassium 3.5 mEq/L (3.5 to 5.0 mEq/L)

Chloride 90 mEq/L (98 to 106 mEq/L)

BUN 8 mg/dL (10 to 20 mg/dL)

Magnesium 1.2 mEq/L (1.3 to 2.1 mEq/L)

Exhibit 3

Vital Signs

1230:

Temperature 37.6° C(99.7°F)

Heart rate 98/min

Respiratory rate 20/min

Blood pressure 142/92 mm Hg

Oxygen saturation 100% on room air

1500:

Temperature 37.1° C(98.8° F)

Heart rate 104/min

Respiratory rate 24/min

Blood pressure 150/90 mm Hg

Oxygen saturation 100% on room air

Exhibit 4

Nurses' Notes

0730:

Client sleeping. Lungs clear to auscultation bilaterally.

Hyperactive bowel sounds noted x 4. Abdomen soft and

nontender. Small bruise noted on right hand. Family at bedside.

Family states client is diagnosed with schizophrenia, and last

doctor's appointment was 6 months ago.

1500:

Client alert and oriented to person and place. Agitated. Speech

disorganized. Client has involuntary tongue movement and foot

tremor. Lungs clear to auscultation bilaterally. Hyperactive

bowel sounds noted x 4. Abdomen soft and nontender. Small

bruise noted on right hand. Client reports an increase in

urination and had one episode of incontinence. Family noticed

increased agitation and delusions.

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again. Day 1 0730: Client sleeping. Lungs clear to auscultation bilaterally. Hyperactive bowel sounds noted x 4. Abdomen soft and nontender. Small bruise noted on right hand. Family at bedside. Family states client is diagnosed with schizophrenia, and last doctor's appointment was 6 months ago. 1500: Client alert and oriented to person and place. Agitated. Speech disorganized. Client has involuntary tongue movement and foot tremor. Lungs clear to auscultation bilaterally. Abdomen soft and nontender. Small bruise noted on right hand. Client reports an increase in urination and had one episode of incontinence. Family noticed increased agitation and delusions.
Transcribed Image Text:Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again. Day 1 0730: Client sleeping. Lungs clear to auscultation bilaterally. Hyperactive bowel sounds noted x 4. Abdomen soft and nontender. Small bruise noted on right hand. Family at bedside. Family states client is diagnosed with schizophrenia, and last doctor's appointment was 6 months ago. 1500: Client alert and oriented to person and place. Agitated. Speech disorganized. Client has involuntary tongue movement and foot tremor. Lungs clear to auscultation bilaterally. Abdomen soft and nontender. Small bruise noted on right hand. Client reports an increase in urination and had one episode of incontinence. Family noticed increased agitation and delusions.
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