A patient with chemotherapy-induced nausea has been prescribed metoclopramide. What adverse effect should the nurse report?

Choice A rationale

Hypertension is a condition that should be reported to the healthcare provider before administering phenylephrine. Phenylephrine is a decongestant used to relieve nasal discomfort caused by colds, allergies, and hay fever. It works by shrinking swollen nasal mucous membranes, which relieves nasal congestion. However, it can cause a rise in blood pressure, which could be dangerous for patients with hypertension.

Choice B rationale

Bronchitis is not a contraindication for phenylephrine. However, if the patient has a chronic respiratory condition like bronchitis, it’s always a good idea to discuss any new medications with the healthcare provider.

Choice C rationale

Diarrhea is not a contraindication for phenylephrine. Phenylephrine is not known to cause or worsen diarrhea.

Choice D rationale

Edema is not a contraindication for phenylephrine. However, if the patient has a history of heart disease or high blood pressure, which can sometimes cause edema, they should inform their healthcare provider.

Choice A rationale

Obtaining an extra pillow for the client to use at night may provide some comfort, but it does not address the underlying issue. The client’s continual rubbing of the back of the neck could be a sign of a condition known as akathisia, a common side effect of antipsychotic medications. Akathisia is characterized by a feeling of restlessness and a compulsion to move, and it can often be misinterpreted as anxiety or agitation.

Choice B rationale

Administering a PRN prescription for benztropine is the most appropriate intervention. Benztropine is an anticholinergic medication that is often used to manage the extrapyramidal side effects of antipsychotic medications, such as akathisia. By reducing these side effects, the client’s comfort and adherence to the antipsychotic medication regimen can be improved.

Choice C rationale

Providing the client with a heating pad to place on the neck may offer temporary relief, but it does not address the underlying issue. The client’s continual rubbing of the back of the neck is likely a symptom of akathisia, a side effect of antipsychotic medications. Therefore, interventions should be aimed at managing this side effect rather than just addressing the symptom.

Choice D rationale

Obtaining a prescription for physical therapy services is not the most appropriate immediate response. While physical therapy can be beneficial for many conditions, it is not typically used as the first-line treatment for akathisia, a common side effect of antipsychotic medications.