Forty-eight hours after starting haloperidol, the client is observed standing by the nurse’s station with his neck arched sharply backward. The nurse recognizes that the client:
Is having pseudo-Parkinsonian side effects and needs to have his medication adjusted.
Is experiencing temporary side effects that usually disappear after several days.
Needs to have the dosage increased because of psychotic behavior that is increasing.
Needs immediate treatment and is experiencing an acute dystonic reaction to the drug.
The Correct Answer is D
Choice A Reason:
Pseudo-Parkinsonian side effects, also known as drug-induced parkinsonism, can occur with the use of antipsychotic medications like haloperidol. These side effects include symptoms such as rigidity, bradykinesia, tremor, and postural instability. However, the description of the client’s neck arched sharply backward is more indicative of an acute dystonic reaction rather than pseudo-Parkinsonian side effects. Pseudo-Parkinsonian symptoms typically develop more gradually and do not present with such dramatic posturing.
Choice B Reason:
While some side effects of haloperidol can be temporary and may disappear after several days, the acute dystonic reaction described in the scenario requires immediate intervention. Acute dystonic reactions are characterized by sudden, severe muscle contractions that can be painful and potentially dangerous if they involve the airway. Therefore, it is crucial to address this reaction promptly rather than waiting for it to resolve on its own.
Choice C Reason:
Increasing the dosage of haloperidol in response to the described symptoms would likely exacerbate the situation. The client’s symptoms are not indicative of worsening psychotic behavior but rather an adverse reaction to the medication. Increasing the dosage could lead to more severe side effects and complications. The appropriate response is to treat the acute dystonic reaction and reassess the medication regimen.
Choice D Reason:
An acute dystonic reaction is a known side effect of antipsychotic medications like haloperidol. It involves sudden, severe muscle contractions, often affecting the neck, face, and back. This reaction can be distressing and requires immediate treatment with anticholinergic medications such as benztropine or diphenhydramine. Prompt intervention can relieve the symptoms and prevent further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
The client’s perception of the event, the availability of supports, and the availability of adequate coping mechanisms.
This is the correct response. A client’s perception of a stressful event plays a crucial role in determining whether they experience a crisis. If the client views the event as overwhelming and beyond their ability to cope, they are more likely to experience a crisis. Additionally, the availability of social supports, such as family, friends, and community resources, can provide emotional and practical assistance, reducing the likelihood of a crisis. Adequate coping mechanisms, such as problem-solving skills, emotional regulation, and stress management techniques, also play a significant role in helping the client manage stress effectively.
Choice B Reason:
Previous experiences, the availability of medication, and the desire to cope.
While previous experiences can influence how a client responds to stress, they are not the sole determinants of whether a crisis will occur. The availability of medication can help manage symptoms of stress or anxiety, but it does not address the underlying perception of the event or the availability of supports. The desire to cope is important, but without adequate coping mechanisms and support, it may not be sufficient to prevent a crisis.
Choice C Reason:
Faith in the psychiatrist, the availability of financial resources, and previous level of functioning.
Faith in the psychiatrist and the availability of financial resources can provide some support, but they do not directly address the client’s perception of the event or their coping mechanisms. Previous level of functioning is important, but it is not the primary factor in determining whether a crisis will occur. The client’s current perception and available supports are more critical in this context.
Choice D Reason:
The time of day, the client’s mood, and the availability of escape from the situation.
The time of day and the client’s mood can influence their immediate response to stress, but they are not the primary determinants of whether a crisis will occur. The availability of escape from the situation may provide temporary relief, but it does not address the underlying perception of the event or the availability of supports and coping mechanisms.
Correct Answer is A
Explanation
Choice A Reason:
“This is a difficult transition. Let’s formulate a plan to keep you feeling safe.”
This response is the most supportive because it acknowledges the client’s feelings and offers a proactive solution. By recognizing the difficulty of the transition and suggesting a plan to ensure the client’s safety, the nurse provides reassurance and practical support. This approach helps to build trust and shows empathy, which is crucial in a therapeutic relationship.
Choice B Reason:
“It’s the policy that patients can only live here for 30 days. Let’s try to extend it.”
While this response acknowledges the client’s fear, it focuses on policy rather than addressing the client’s immediate emotional needs. Extending the stay might not be feasible or beneficial in the long term. The primary goal should be to empower the client to feel safe and supported outside the facility.
Choice C Reason:
“You’ve had a month to come up with a plan to work on your well-being.”
This response can come across as dismissive and unsupportive. It implies that the client should have already resolved their fears, which may increase their anxiety and feelings of inadequacy. The focus should be on providing immediate support and reassurance rather than criticizing the client’s progress.
Choice D Reason:
“Hopefully you learned from being in counseling. I’m sure this will work out fine.”
This response is overly optimistic and does not address the client’s current fears. It provides false reassurance without offering any concrete support or solutions. The client needs to feel heard and supported, not just reassured that everything will be fine.
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