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 B

Explanation

Choice A rationale

While it’s understandable that the patient’s daughter wants to delay the use of medication until her mother’s symptoms worsen, this approach may not be beneficial. Rivastigmine, a cholinesterase inhibitor, is used to treat mild to moderate dementia caused by Alzheimer’s or Parkinson’s disease. It is not a cure for Alzheimer’s or Parkinson’s disease, but it can help manage the symptoms. Waiting until the symptoms worsen may not provide the desired benefits and could potentially lead to a faster progression of the disease.

Choice B rationale

Rivastigmine is most effective when used early in the disease process. It works by increasing the concentration of acetylcholine, a neurotransmitter, through reversible inhibition of its hydrolysis by cholinesterase. This can help improve the function of nerve cells in the brain and can slow the progression of symptoms in patients with Alzheimer’s disease. Therefore, starting the medication early can help manage the symptoms and potentially slow the progression of the disease.

Choice C rationale

While assessing the patient’s current mental status is an important part of care, it should not be the sole factor in deciding when to start medication. The decision to start medication should be based on a comprehensive evaluation of the patient’s condition, including the stage of the disease, the patient’s overall health, and the potential benefits and risks of the medication.

Choice D rationale

While it’s important for the daughter to understand the progressive nature of Alzheimer’s disease, this understanding alone does not determine when to start medication. The decision to start medication should be based on a comprehensive evaluation of the patient’s condition and the potential benefits and risks of the medication.

A. One hour after completion of the IV dose and one hour before the next administration of the medication. B. Two hours after completion of the IV dose and two hours before the next administration of the medication. C. Thirty minutes into the administration of the IV dose and 30 minutes before the next administration of the medication. D. Immediately after completion of the IV dose and 30 minutes before the next administration of the medication.

Correct Answer is D

Explanation

The correct answer is D. Immediately after completion of the IV dose and 30 minutes before the next administration of the medication.

Explanation:

Peak levels measure the highest concentration of the drug in the bloodstream, typically drawn immediately after completion of the infusion.
Trough levels measure the lowest concentration, typically drawn 30 minutes before the next scheduled dose to ensure effective drug levels while preventing toxicity.

Why the other options are incorrect:

A. One hour after completion of the IV dose and one hour before the next administration – Waiting one hour for the peak level could lead to an inaccurate measurement, as the drug may already be metabolized or distributed.
B. Two hours after completion of the IV dose and two hours before the next administration – This timing is too late for both peak and trough levels, missing the best points for measurement.
C. Thirty minutes into the administration of the IV dose and 30 minutes before the next administration – The sample drawn mid-infusion does not represent peak levels, making this method ineffective.

Key takeaway:

Peak and trough monitoring for vancomycin is essential to maximize effectiveness while avoiding nephrotoxicity and ototoxicity. Proper timing ensures accurate therapeutic drug monitoring.

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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

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?

Correct Answer is D

Explanation

Explanation:

Why the other options are incorrect:

Key takeaway:

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