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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["42"]

Explanation

To calculate the infusion rate in gtt/min, we first need to calculate the infusion rate in mL/hr. The formula for this is:

Step 1: Calculate the infusion rate in mL/hr

Infusion rate (mL/hr)=Total time (hr)Total volume (mL) Substituting the given values: Infusion rate (mL/hr)=2 hr mL=250 mL/hr

Step 2: Convert the infusion rate from mL/hr to gtt/min Infusion rate (gtt/min)=60 min/hrInfusion rate (mL/hr)×Drop factor (gtt/mL).

Substituting the given values: Infusion rate (gtt/min)=60 min/hr mL/hr×10 gtt/mL ≈42 gtt/min Therefore, the nurse should regulate the infusion to approximately 42 gtt/min.

A. Administer sucralfate once daily, preferably at bedtime. B. Give sucralfate on an empty stomach. C. Monitor for a secondary Candida infection. D. Monitor for electrolyte imbalances.

Correct Answer is B

Explanation

Choice A rationale

Sucralfate is not typically administered once daily, preferably at bedtime. It is usually given multiple times a day.

Choice B rationale

Sucralfate should be given on an empty stomach, at least one hour before meals and at bedtime. This is because the absorption of sucralfate can be affected by the presence of food in the stomach.

Choice C rationale

While it’s important to monitor for infections when administering any medication, there’s no specific association between sucralfate and secondary Candida infections.

Choice D rationale

Sucralfate does not typically cause electrolyte imbalances. Its main function is to form a protective barrier over the ulcer, preventing further damage from acid and pepsin.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 patient is receiving a secondary infusion of azithromycin 500 mg in 500 mL of normal saline (NS) to be infused over 2 hours. The intravenous (IV) administration set delivers 10 gtt/mL. How many gtt/min should the nurse regulate the infusion?

Correct Answer is ["42"]

Explanation

The nurse is preparing to administer the anti-ulcer gastrointestinal agent sucralfate to a patient with peptic ulcer disease.What should be included in this patient’s care plan?

Correct Answer is B

Explanation

A client is receiving intravenous vancomycin, and the nurse plans to draw blood for a peak and trough to determine the serum level of the drug. Which collection times would provide the best determination of these levels?

Before administering the evening dose of carbamazepine, the nurse notes that the patient’s morning carbamazepine level was 84 mcg/mL. What action should the nurse take?

A patient with peptic ulcer disease has been prescribed cimetidine.Which statement made by the patient indicates the need for further instruction by the nurse?

A patient in a residential treatment facility uses a fluticasone propionate and salmeterol discus inhalation system to manage asthma.This system delivers an inhaled powdered form of these combined medications. What instruction should the nurse provide to this patient’s caregivers?

A female patient with multiple sclerosis reports less fatigue and improved memory since she started using the herbal supplement, ginkgo biloba.What is the most important information for the nurse to include in the teaching plan for this patient?

A patient with open-angle glaucoma asks the nurse about the duration of use for the prescribed eye drops. What is the nurse’s accurate response?

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?

The nurse administers risedronate to a client with osteoporosis at 0700. The client asks for a glass of milk to drink with the medication.What action should the nurse take?