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 D

Explanation

A) Request backup from the staff:Requesting backup may be necessary if the situation escalates and the client poses a threat to themselves or others. However, it should not be the first action. The nurse should initially attempt to de-escalate the situation by addressing the client’s immediate needs and providing personal space.

B) Encourage the client to sit down:Encouraging the client to sit down might help reduce their agitation, but it could also be perceived as controlling or dismissive. The nurse should first focus on creating a safe environment by providing personal space and then assess the client’s willingness to sit down.

C) Stand in the doorway:Standing in the doorway can provide the nurse with a quick exit if needed, but it may also make the client feel trapped or cornered. It is important to maintain a non-threatening posture and ensure the client has enough space to feel comfortable.

D) Provide for personal space:Providing personal space is crucial in managing aggressive behaviors. It helps to reduce the client’s sense of threat and allows them to feel more in control. This approach can help de-escalate the situation and create a safer environment for both the client and the nurse.

A. Tell the client that irrational thinking is a symptom of schizophrenia. B. Obtain an order for a tube feeding for the client. C. Assure the client that all food served in the hospital is safe to eat. D. Provide the client with food in unopened containers.

Correct Answer is D

Explanation

A) Telling the client that irrational thinking is a symptom of schizophrenia may come across as dismissive and could further alienate the client. While it's important to acknowledge the symptoms, this approach does not provide a practical solution to the immediate concern of the client refusing to eat.

B) Obtaining an order for tube feeding should be a last resort. While nutritional intake is essential, invasive interventions should only be considered if the client’s refusal to eat poses an immediate health risk and after other less invasive strategies have been attempted.

C) Assuring the client that all food served in the hospital is safe to eat might be well-intentioned, but it is unlikely to alleviate the client's fears. The client is experiencing

delusions, and simply stating that the food is safe may not be convincing.

D) Providing the client with food in unopened containers is the most appropriate intervention. This respects the client's concerns about food safety while offering a solution that allows them to eat without directly confronting their delusions. Unopened containers can provide a sense of security and control for the client, potentially encouraging them to consume food without feeling threatened.

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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?

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Explanation

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