A client with psychosis is receiving an antipsychotic medication and is continually rubbing the back of the neck. What is the best nursing intervention?

Obtain an extra pillow for the client to use at night.

Give a PRN prescription for benztropine.

Provide the client a heating pad to place on the neck.

Obtain a prescription for physical therapy services.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Obtaining an extra pillow for the client to use at night may provide some comfort, but it does not address the underlying issue. The client’s continual rubbing of the back of the neck could be a sign of a condition known as akathisia, a common side effect of antipsychotic medications. Akathisia is characterized by a feeling of restlessness and a compulsion to move, and it can often be misinterpreted as anxiety or agitation.

Choice B rationale

Administering a PRN prescription for benztropine is the most appropriate intervention. Benztropine is an anticholinergic medication that is often used to manage the extrapyramidal side effects of antipsychotic medications, such as akathisia. By reducing these side effects, the client’s comfort and adherence to the antipsychotic medication regimen can be improved.

Choice C rationale

Providing the client with a heating pad to place on the neck may offer temporary relief, but it does not address the underlying issue. The client’s continual rubbing of the back of the neck is likely a symptom of akathisia, a side effect of antipsychotic medications. Therefore, interventions should be aimed at managing this side effect rather than just addressing the symptom.

Choice D rationale

Obtaining a prescription for physical therapy services is not the most appropriate immediate response. While physical therapy can be beneficial for many conditions, it is not typically used as the first-line treatment for akathisia, a common side effect of antipsychotic medications.

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Correct Answer is C

Explanation

Choice A rationale

Excessive bruising is not a typical side effect of atorvastatin, and it is not linked to increased CK levels. Excessive bruising can be caused by bleeding disorders, anticoagulant therapy, or trauma.

Choice B rationale

Peripheral edema is not a common side effect of atorvastatin, and it is not related to increased CK levels. CK is an enzyme that is released when muscle tissue is damaged. Peripheral edema is more likely to be caused by heart failure, kidney disease, or venous insufficiency.

Choice C rationale

Muscle tenderness is a sign of myopathy, which is a rare but serious adverse effect of atorvastatin. Myopathy is a condition where muscle fibers are damaged and inflamed, leading to muscle weakness and pain. Increased CK levels indicate muscle injury and can be a marker of myopathy. The nurse should monitor the client for muscle symptoms and report them to the prescriber.

Choice D rationale

Nausea and vomiting are common gastrointestinal side effects of atorvastatin, but they are not associated with increased CK levels. Nausea and vomiting can be managed by taking the medication with food or reducing the dose.

A. Administer a second dose of naloxone. B. Prepare to assist with chest tube insertion. C. Determine Glasgow Coma Scale score. D. Initiate cardiopulmonary resuscitation (CPR). .

Correct Answer is D

Explanation

The correct answer is choice D: Initiate cardiopulmonary resuscitation (CPR).

Choice D rationale: The patient's respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and unresponsiveness indicate severe respiratory depression, which requires immediate intervention. CPR is the priority action to maintain circulation and oxygenation while awaiting further interventions.

Choice A rationale: Administering a second dose of naloxone may be necessary to counteract the effects of opioids. However, in this case, the patient's condition has severely deteriorated, and immediate resuscitation efforts take priority.

Choice B rationale: Preparing to assist with chest tube insertion is not the appropriate action in this situation. Chest tube insertion is used to treat conditions like pneumothorax or pleural effusion, which are not indicated in this scenario.

Choice C rationale: Determining the Glasgow Coma Scale score is useful for assessing the patient's level of consciousness but should not be the first action in this case. Ensuring adequate circulation and oxygenation through CPR is the priority.

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A client with psychosis is receiving an antipsychotic medication and is continually rubbing the back of the neck. What is the best nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client taking atorvastatin has an increased serum creatine phosphokinase (CK) level. What should the nurse assess the client for?

Correct Answer is C

Explanation

The nurse administers naloxone to a patient with opioid-induced respiratory depression. An hour later, the nurse finds the patient has a respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and is unresponsive. What action should the nurse take?

Correct Answer is D

Explanation

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