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 A
Explanation
Choice A rationale
Hypertension is a condition that should be reported to the healthcare provider before administering phenylephrine. Phenylephrine is a decongestant used to relieve nasal discomfort caused by colds, allergies, and hay fever. It works by shrinking swollen nasal mucous membranes, which relieves nasal congestion. However, it can cause a rise in blood pressure, which could be dangerous for patients with hypertension.
Choice B rationale
Bronchitis is not a contraindication for phenylephrine. However, if the patient has a chronic respiratory condition like bronchitis, it’s always a good idea to discuss any new medications with the healthcare provider.
Choice C rationale
Diarrhea is not a contraindication for phenylephrine. Phenylephrine is not known to cause or worsen diarrhea.
Choice D rationale
Edema is not a contraindication for phenylephrine. However, if the patient has a history of heart disease or high blood pressure, which can sometimes cause edema, they should inform their healthcare provider.
Correct Answer is C
Explanation
Choice A rationale
While it is important to assess for hypoglycemia between meals when a client is receiving insulin lispro, this is not the most important intervention. Hypoglycemia is a potential side effect of all insulins, but the timing of the hypoglycemia is often related to the timing of the insulin dose and meals.
Choice B rationale
Checking blood glucose levels every six hours is a part of diabetes management. However, this is not the most important intervention for a client who is receiving insulin lispro. The timing of blood glucose checks should be individualized based on the client’s needs and the type of insulin they are receiving.
Choice C rationale
Insulin lispro is a rapid-acting insulin that begins to work very quickly. For this reason, it should be given at the same time as meals. This is the most important intervention for a client who is receiving insulin lispro.
Choice D rationale
Keeping an oral liquid or glucose source available is important for all clients with diabetes to treat potential hypoglycemia. However, this is not the most important intervention for a client who is receiving insulin lispro.
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