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.
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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Related Questions
Correct Answer is D
Explanation
Intermittent claudication is a condition in which there is pain in the legs due to reduced blood flow. Pentoxifylline is a medication that can improve blood flow by reducing the viscosity of the blood. Therefore, to determine the effectiveness of the medication in managing intermittent claudication, the nurse should monitor the client's pain level using a numeric pain scale. This will help to assess if the medication provides pain relief and improving the client's ability to walk without discomfort.
Options a, b, and c are not relevant to the assessment of the effectiveness of pentoxifylline in managing intermittent claudication.
Correct Answer is B
Explanation
Spironolactone is a potassium-sparing diuretic that works by blocking the actions of aldosterone, a hormone that can lead to potassium loss in the urine. However, in some cases, spironolactone can cause hyperkalemia (high levels of potassium in the blood), which can be dangerous for patients with heart failure. Therefore, it is important to instruct the patient to limit their intake of high-potassium foods such as bananas, oranges, tomatoes, spinach, and salt substitutes containing potassium.
Option a (Replace salt with a salt substitute) is incorrect because salt substitutes often contain potassium, which can further increase the risk of hyperkalemia.
Option c (Cover your skin before going outside) is unrelated to the use of spironolactone and hyperkalemia.
Option d (Monitor skin for excessive bruising) is not directly related to the use of spironolactone and hyperkalemia, although it is a potential side effect of other medications used to treat heart failure.
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