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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Determining when the last dose was administered is an important step in managing a client’s pain. However, it should not be the first action taken when a client requests the largest possible dose of pain medication. The nurse first needs to assess the client’s current level of pain to determine the appropriate intervention.
Choice B rationale
Reviewing the history for past use of recreational drugs is an important part of a comprehensive pain assessment. However, it should not be the first action taken when a client requests the largest possible dose of pain medication. The nurse first needs to assess the client’s current level of pain to determine the appropriate intervention.
Choice C rationale
Asking the client to rate the current level of pain using a pain scale should be the first action the nurse takes when a client requests the largest possible dose of pain medication. Pain is subjective and can only be accurately assessed by the person experiencing it. Using a pain scale helps the nurse quantify the client’s pain and guide appropriate interventions.
Choice D rationale
Encouraging the client to use diversional thoughts to manage pain can be a helpful non- pharmacological pain management strategy. However, it should not be the first action taken when a client requests the largest possible dose of pain medication. The nurse first needs to assess the client’s current level of pain to determine the appropriate intervention.
Correct Answer is C
Explanation
Choice A rationale
Iron supplements can interfere with the absorption of levothyroxine, reducing its effectiveness. However, this doesn’t mean that iron should be completely avoided. It’s generally recommended to take iron supplements and levothyroxine at different times of the day.
Choice B rationale
While iodine is a key component of thyroid hormones, consuming foods high in iodine doesn’t necessarily improve the effectiveness of levothyroxine. In fact, excessive iodine intake can sometimes cause or worsen hypothyroidism.
Choice C rationale
Levothyroxine should be taken on an empty stomach, typically 30 minutes to an hour before breakfast. This allows for optimal absorption of the medication.
Choice D rationale
Although it’s not harmful to take levothyroxine at bedtime, studies suggest that taking it on an empty stomach in the morning may allow for better absorption.
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