A client with schizophrenia receives a prescription for fluphenazine. Which instruction is most important for the nurse to include when teaching the client about this drug?

Wear sunscreen when going outside to prevent effects of sun sensitivity.

Notify your healthcare provider immediately if involuntary movements develop.

Drink water frequently throughout the day as the medication increases thirst.

Check blood pressure daily and notify the healthcare provider if it increases

Answer and Explanation

The Correct Answer is B

A) Wearing sunscreen when going outside to prevent effects of sun sensitivity is important for clients taking certain antipsychotic medications, but it is not the most critical instruction. While fluphenazine can cause photosensitivity, the risk of developing involuntary movements (extrapyramidal symptoms) is a more immediate concern that could significantly affect the client’s quality of life.

B) Notifying the healthcare provider immediately if involuntary movements develop is crucial when taking fluphenazine. This medication can lead to extrapyramidal symptoms such as tardive dyskinesia or acute dystonia, which require prompt assessment and intervention to prevent long-term complications. Educating the client about these potential side effects empowers them to seek timely help.

C) Drinking water frequently throughout the day is generally good advice for overall hydration, but fluphenazine does not significantly increase thirst. While maintaining hydration is important, the focus should be on the potential for serious side effects like involuntary movements, making this instruction secondary in priority.

D) Checking blood pressure daily and notifying the healthcare provider if it increases is relevant for some medications, particularly antihypertensives or those that can cause orthostatic hypotension. However, with fluphenazine, the more critical instruction revolves around recognizing and responding to neurological side effects rather than routine blood pressure monitoring, making this less of a priority.

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Correct Answer is A

Explanation

A) Reviewing serum creatinine is the most critical laboratory finding prior to initiating lithium therapy. Lithium is primarily excreted through the kidneys, and any existing renal impairment can increase the risk of lithium toxicity. Ensuring normal kidney function is vital for safe lithium administration and monitoring throughout the treatment.

B) While blood glucose levels can be relevant in the context of overall health and any potential metabolic syndrome concerns, they are not as directly related to lithium therapy as renal function. Blood glucose levels do not significantly impact the safety or effectiveness of lithium.

C) A white blood count (WBC) can be important in assessing for potential infections or hematological disorders, but it is not the primary focus when starting lithium. Lithium does not typically have a direct effect on white blood cell levels, making this finding less critical compared to renal function.

D) Alkaline phosphatase levels are primarily related to liver function and bone health. While monitoring liver function is important in general, it is not as directly pertinent to the initiation of lithium therapy as assessing renal function through serum creatinine levels. Therefore, this laboratory finding is less of a priority in this context.

A. Listen to what the client is saying B. Sit in the chair next to the client. C. Escort the client to his room. D. Administer a PRN sedative.

Correct Answer is C

Explanation

A) Listening to what the client is saying can be important for understanding their perspective, but in this situation, the client's loud and wild behavior may be disruptive or alarming to others. Prioritizing safety is crucial.

B) Sitting in the chair next to the client could help establish rapport, but it does not address the immediate need to manage the disruptive behavior. The nurse must first ensure a safe environment for all clients.

C) Escorting the client to his room is the best initial action. This intervention helps to remove the client from the potentially stimulating environment of the day room, reducing the likelihood of escalation and providing a quieter space where the client can feel more secure and calm. It also minimizes disruption to other clients.

D) Administering a PRN sedative may be necessary if the behavior continues to escalate, but it should not be the first action taken. Non-pharmacological interventions, such as providing a safe space, should be prioritized before considering medication.

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A client with schizophrenia receives a prescription for fluphenazine. Which instruction is most important for the nurse to include when teaching the client about this drug?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The healthcare provider prescribes lithium carbonate for a client diagnosed with bipolar, manic depression. It is most important for the nurse to review which laboratory finding prior to beginning the drug therapy?

Correct Answer is A

Explanation

A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit's day room. Which action should the nurse implement first?

Correct Answer is C

Explanation

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