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 B

Explanation

A) Advising the client to reschedule until committing to recovery may come across as dismissive and could discourage the client from making positive changes. It’s important to support any intention to improve rather than setting conditions that might lead to feelings of failure or frustration.

B) Supporting the client to list small behavioral changes needed is the best response. This approach empowers the client by encouraging them to take manageable steps toward their goals. Focusing on small changes can enhance the client's confidence and motivation, making the process of leading a healthier lifestyle more achievable.

C) Explaining the specific skills needed to prevent relapse is important, but it may be overwhelming for the client at this stage. The focus should be on fostering a sense of hope and readiness for change rather than diving immediately into complex relapse prevention strategies.

D) Providing teaching on the symptoms of substance use dependence might be relevant, but it may not directly support the client's desire for change. The client is expressing a wish to move forward, so it’s more beneficial to focus on positive actions rather than reiterating the challenges of dependence. Supporting behavioral change aligns better with the client’s expressed intentions.

A. Stay quietly with the client. B. Tell her that she is out of control. C. Ignore the client's acting out, behavior. D. Distract her by offering finger foods.

Correct Answer is A

Explanation

A) Staying quietly with the client is the best approach in this situation. By remaining present and calm, the nurse can provide a sense of safety and support. This non-confrontational presence may help the client feel more secure and reduce her agitation over time.

B) Telling the client that she is out of control may escalate her frustration and feelings of being judged. This could worsen the situation rather than help it, as it does not offer any constructive feedback or support.

C) Ignoring the client's acting out behavior is not appropriate. Acknowledging her feelings and providing support is essential, even if her behavior is challenging. Ignoring her could lead to further escalation and feelings of isolation.

D) Distracting her by offering finger foods could be an effective strategy if the client is calm enough to engage in that activity. However, if she is currently shouting and screaming, she may not be receptive to distraction techniques. Addressing her emotional state first is more critical.

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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

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