A nurse is caring for a client with schizophrenia who has been receiving haloperidol for the past 10 days. The client becomes increasingly restless, frequently shifting in their chair, and states. "I feel like I need to keep moving, but I don't know why." Vitals are stable, and no distress is reported aside from the restlessness. Which of the following actions should the nurse take first?
Reassure the client that this is a temporary side effect.
Document the finding as an expected response to antipsychotic medication.
Notify the provider and request a dose reduction of haloperidol.
Administer the prescribed dose of diphenhydramine PRN
The Correct Answer is D
Rationale:
A. Reassurance alone does not address the underlying cause of the restlessness, which may be distressing and impair functioning.
B. Although this can be an expected side effect (akathisia), documenting without intervention neglects the client's discomfort.
C. Notifying the provider is important, but immediate symptom relief is the priority before adjusting long-term therapy.
D. The client is exhibiting signs of akathisia, a common extrapyramidal side effect of haloperidol. Diphenhydramine (an anticholinergic/antihistamine) can relieve symptoms promptly and should be administered as the first nursing action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. While this question opens communication, it shifts the focus to others instead of validating the client’s current emotional state.
B. This is a nontherapeutic response that minimizes the client’s feelings and offers false reassurance.
C. This can evoke guilt and is not therapeutic—it shifts the focus away from the client’s emotions and may increase their distress.
D. This response demonstrates empathy, acknowledges the client’s emotional pain, and shows willingness to listen—a cornerstone of therapeutic communication.
Correct Answer is C
Explanation
Rationale:
A. Open-ended questions are more effective when anxiety is mild to moderate, not when the client is in a panic state and unable to process information.
B. Exploring anxiety triggers requires a higher level of cognitive function, which is impaired in severe or panic-level anxiety.
C. The client is displaying signs of panic-level anxiety (disorientation, inability to follow instructions, hyperventilation). In this state, the nurse should use short, clear, and direct instructions delivered in a calm, firm tone to promote safety and grounding.
D. Educational materials are not helpful during panic; the client is not in a state to absorb new information.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.