A nurse is educating a group of nursing students about brain herniation.
Which of the following interventions should the nurse include as a potential treatment for brain herniation?

Choice A rationale

Constipation is a potential side effect of aripiprazole, but it is not typically a serious concern that would require notifying the provider.

Choice B rationale

Weight gain of 5 lb in 1 month could be a side effect of aripiprazole, but it is not typically a serious concern that would require notifying the provider.

Choice C rationale

Insomnia is a potential side effect of aripiprazole, but it is not typically a serious concern that would require notifying the provider.

Choice D rationale

Muscle stiffness could be a sign of a serious side effect of aripiprazole known as extrapyramidal symptoms. This could include conditions such as dystonia, akathisia, and Parkinsonism. If a patient experiences muscle stiffness while taking aripiprazole, the healthcare provider should be notified.

Essential

1. Monitoring respiratory rate closely: The client is breathing rapidly and appears anxious, making close monitoring crucial to ensure timely intervention and management of respiratory issues.

2. Providing reassurance and calming interventions: The client is anxious and discomforted. Providing reassurance and calming interventions is important to address their immediate emotional and psychological needs.

3. Checking electrolyte levels regularly: Given the client's symptoms and the need for ongoing monitoring, checking electrolyte levels is essential for managing their condition effectively.

Nonessential

1. Administering antiemetic medication: While helpful for managing nausea, this action is not immediately critical compared to other interventions that address more urgent needs.

Contraindicated

1. Encouraging the client to sit up without assistance: The client feels faint and is unsteady when sitting up. Encouraging them to sit up without assistance could be dangerous and may increase the risk of falls or injuries.

2. Increasing IV fluid rate: The current IV fluid rate is prescribed by the provider. Increasing it without further assessment could lead to complications and should be avoided unless directed by a healthcare provider.