A nurse on a mental health unit observes a patient diagnosed with schizophrenia on antipsychotics exhibiting an impaired gait and uncontrollable tremors. The nurse should recognize that which of the following adverse effects may be occurring?

Acute dystonia

Pseudoparkinsonism

Neuroleptic malignant syndrome

Tardive dyskinesia

Answer and Explanation

The Correct Answer is B

Choice A reason:

Acute dystonia is a type of extrapyramidal side effect that can occur with antipsychotic medications. It typically presents as muscle spasms, stiffness, and oculogyric crisis. While it can affect gait and cause tremors, these symptoms are more commonly associated with pseudoparkinsonism when they appear as part of a medication side effect profile.

Choice B reason:

Pseudoparkinsonism is an adverse effect of antipsychotic medications that mimics the symptoms of Parkinson's disease, such as bradykinesia, rigidity, tremors, and postural instability. The impaired gait and uncontrollable tremors observed by the nurse are characteristic signs of pseudoparkinsonism.

Choice C reason:

Neuroleptic malignant syndrome (NMS) is a rare but serious condition associated with the use of antipsychotic medications. It presents with severe muscle rigidity, fever, autonomic instability, and altered mental status. While tremors can be a symptom, the defining features of NMS are high fever and muscle rigidity, which were not mentioned in the scenario.

Choice D reason:

Tardive dyskinesia is a late-onset side effect of antipsychotic medications characterized by repetitive, involuntary, and purposeless movements such as grimacing, tongue protrusion, lip smacking, and blinking. It does not typically present with an impaired gait or tremors, which are more indicative of pseudoparkinsonism.

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Correct Answer is ["B","C","D","F"]

Explanation

Choice A: Set up a dietary consult for a low-sodium diet.

Reason: While a low-sodium diet is generally recommended for clients with heart failure to manage fluid retention and blood pressure, it is not the immediate priority in this scenario. The client’s current symptoms and lab results indicate lithium toxicity, which requires more urgent interventions.

Choice B: Notify the provider of potential medication interactions.

Reason: The client is taking lithium and furosemide, which can interact and increase the risk of lithium toxicity. Furosemide, a diuretic, can cause dehydration and electrolyte imbalances, exacerbating lithium toxicity. Notifying the provider is crucial to address these interactions and adjust medications accordingly.

Choice C: Withhold next dose of lithium.

Reason: The client’s lithium level is 2.2 mEq/L, which is above the therapeutic range (0.8 to 1.2 mEq/L) and indicates toxicity. Symptoms such as vomiting, diarrhea, muscle twitching, slurred speech, and drowsiness further support this. Withholding the next dose of lithium is necessary to prevent worsening toxicity2.

Choice D: Educate the client about the need for hemodialysis.

Reason: In cases of severe lithium toxicity, hemodialysis may be required to rapidly remove lithium from the body. Given the client’s high lithium level and symptoms, educating them about this potential treatment is important.

Choice E: Discuss contraception.

Reason: While discussing contraception is important for clients on lithium due to potential teratogenic effects, it is not an immediate priority in this acute situation. The focus should be on addressing the lithium toxicity and stabilizing the client.

Choice F: Assess need for and administer prochlorperazine PRN.

Reason: The client has been experiencing nausea and vomiting, which are symptoms of lithium toxicity2. Administering prochlorperazine can help manage these symptoms and provide relief. However, it is essential to monitor the client closely due to potential interactions with other medications.

A. "What are the voices telling you to do?" B. "You need to tell the voices to leave you alone." C. "You need to understand that there are no voices." D. "Why do you think you are hearing the voices?"

Correct Answer is A

Explanation

Choice A Reason:

The response "What are the voices telling you to do?" is appropriate because it allows the nurse to assess the content of the hallucinations and determine if there is an immediate risk of harm to the client or others. This approach shows empathy and concern for the client's experience while gathering crucial information to ensure safety. Understanding the nature of the voices can help the nurse provide appropriate interventions and support.

Choice B Reason:

Telling the client "You need to tell the voices to leave you alone" is not an effective response. This statement can be dismissive and may not acknowledge the client's distress. Clients with schizophrenia may not have the ability to control their hallucinations, and this response does not provide the necessary support or validation of their experience.

Choice C Reason:

The statement "You need to understand that there are no voices" is dismissive and invalidates the client's experience. Clients with schizophrenia perceive their hallucinations as real, and telling them that the voices do not exist can increase their distress and mistrust. It is important to acknowledge the client's experience while providing reassurance and support.

Choice D Reason:

Asking "Why do you think you are hearing the voices?" may not be helpful in the moment of acute distress. This question can be confusing and does not address the client's immediate fear and anxiety. The priority should be to assess the content of the hallucinations and ensure the client's safety rather than exploring the reasons behind the hallucinations.

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A nurse on a mental health unit observes a patient diagnosed with schizophrenia on antipsychotics exhibiting an impaired gait and uncontrollable tremors. The nurse should recognize that which of the following adverse effects may be occurring?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client to the mental health unit. Exhibits The nurse is developing a plan of care for the client. Which of the following interventions should the nurse include? (Select all that apply.)

Correct Answer is ["B","C","D","F"]

Explanation

Choice A: Set up a dietary consult for a low-sodium diet.

Choice B: Notify the provider of potential medication interactions.

Choice C: Withhold next dose of lithium.

Choice D: Educate the client about the need for hemodialysis.

Choice E: Discuss contraception.

Choice F: Assess need for and administer prochlorperazine PRN.

A nurse is talking with a client diagnosed with schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate?

Correct Answer is A

Explanation

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A nurse on a mental health unit observes a patient diagnosed with schizophrenia on antipsychotics exhibiting an impaired gait and uncontrollable tremors. The nurse should recognize that which of the following adverse effects may be occurring?

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