A client with psychosis who is receiving an antipsychotic medication is continuously rubbing the back of the neck. Which nursing intervention is best for the nurse to implement?

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

Provide the client with a heating pad to place around the neck.

Give PRN prescription for benztropine.

Obtain a prescription for physical therapy services.

Answer and Explanation

The Correct Answer is C

Continuous rubbing of the back of the neck can be a side eﬀect of antipsychotic medication, known as acute dystonia. Benztropine is an anticholinergic medication that can eﬀectively treat acute dystonia. Therefore, the nurse should give a PRN prescription for benztropine to relieve the client's discomfort. Options a, b, and d do not address the underlying issue of acute dystonia and are not the best interventions for this particular situation.

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Correct Answer is D

Explanation

Sucralfate is a medication used to treat and prevent the return of duodenal ulcers. It is important to take sucralfate on an empty stomach, either 1 hour before meals or 2 hours after meals. This allows the medication to work eﬀectively by sticking to damaged ulcer tissue and protecting against acid and enzymes so healing can occur.

A. Determine if the full course of the initial prescription of medication was taken. B. Explain that the diarrhea may be an adverse eﬀect that requires further evaluation. C. Oﬀer instructions about the use of an over-the-counter antidiarrheal medication. D. advise that the infection has returned, and additional medication will be needed.

Correct Answer is B

Explanation

Nitrofurantoin is an antibiotic commonly used to treat urinary tract infections. One of the adverse eﬀects of nitrofurantoin is diarrhea, which may be severe and watery. Therefore, it is important for the home care nurse to inform the client that the diarrhea may be a side eﬀect of the medication and requires further evaluation. The nurse should instruct the client to stop taking the medication and contact their healthcare provider for further assessment and treatment. The nurse should also assess the client's ﬂuid and electrolyte status and monitor for signs of dehydration.

Option a is important to consider, but it does not address the potential adverse eﬀect of the medication.

Option c may be appropriate in some cases, but it is not the priority intervention at this time.

Option d is not necessarily true and may cause unnecessary alarm to the client.

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A client with psychosis who is receiving an antipsychotic medication is continuously rubbing the back of the neck. Which nursing intervention is best for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning to administer the antiulcer GI agent sucralfate to a client with a peptic ulcer disease. Which action should the nurse include in this client’s plan of care?

Correct Answer is D

Explanation

Two months after taking nitrofurantoin for a bacterial infection, a client reports the onset of severe, watery diarrhea to the home care nurse. How should the nurse respond?

Correct Answer is B

Explanation

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