A client with psychosis who is receiving an antipsychotic medication is continually rubbing the back of the neck. Which nursing intervention is best for the nurse to implement?
Provide the client a heating pad to place on the neck.
Obtain a prescription for physical therapy services.
Give a PRN prescription for benztropine.
Obtain an extra pillow for the client to use at night.
The Correct Answer is C
Choice A reason: Providing a heating pad to the client may provide some temporary relief, but it does not address the underlying cause of the neck discomfort, which is likely due to extrapyramidal side effects (EPS) of the antipsychotic medication.
Choice B reason: Obtaining a prescription for physical therapy services may be beneficial for the client's overall health and well-being, but it is not the best intervention for the acute problem of neck discomfort. Physical therapy may also require a referral and a waiting period, which would delay the relief for the client.
Choice C reason: Giving a PRN prescription for benztropine is the best intervention for the nurse to implement, as benztropine is an anticholinergic medication that can counteract the EPS of the antipsychotic medication. Benztropine can reduce the muscle stiffness and spasms that cause the neck discomfort.
Choice D reason: Obtaining an extra pillow for the client to use at night may help the client sleep better, but it does not address the neck discomfort during the day. It also does not treat the EPS of the antipsychotic medication, which may worsen over time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is not the correct time to collect the peak and trough levels. The peak level should be measured after the completion of the IV dose, not during the administration. The trough level should be measured just before the next administration, not 30 minutes before.
Choice B reason: This is the correct time to collect the peak and trough levels. The peak level should be measured one hour after the completion of the IV dose, when the concentration of the medication is highest in the blood. The trough level should be measured one hour before the next administration, when the concentration of the medication is lowest in the blood.
Choice C reason: This is not the correct time to collect the peak and trough levels. The peak level should be measured one hour after the completion of the IV dose, not two hours after. The trough level should be measured one hour before the next administration, not two hours before.
Choice D reason: This is not the correct time to collect the peak and trough levels. The peak level should be measured one hour after the completion of the IV dose, not immediately after. The trough level should be measured one hour before the next administration, not 30 minutes before.
Correct Answer is B
Explanation
Choice A reason: This is not the best assessment for the nurse to use to evaluate the client's therapeutic response to lactulose. Stool color and character may change as a result of lactulose administration, as it is a laxative that lowers the pH of the colon and promotes the excretion of ammonia. However, these changes are not indicative of the effectiveness of lactulose in reducing the ammonia levels in the blood, which is the main goal of the therapy.
Choice B reason: This is the best assessment for the nurse to use to evaluate the client's therapeutic response to lactulose. Serum electrolytes and ammonia are directly affected by lactulose administration, as it lowers the blood ammonia levels by converting it to ammonium and facilitating its elimination in the stool. The nurse should monitor the serum electrolytes and ammonia levels regularly to assess the efficacy and safety of lactulose therapy, as well as to adjust the dosage as needed.
Choice C reason: This is not the best assessment for the nurse to use to evaluate the client's therapeutic response to lactulose. Serum hepatic enzymes are markers of liver function and damage, and they may be elevated in clients with hepatic encephalopathy due to cirrhosis or other liver disorders. However, lactulose does not affect the hepatic enzymes directly, and it does not reverse the underlying liver disease. The nurse should monitor the serum hepatic enzymes to assess the progression and severity of the liver condition, but not to evaluate the response to lactulose.
Choice D reason: This is not the best assessment for the nurse to use to evaluate the client's therapeutic response to lactulose. Fingerstick glucose is a measure of blood glucose levels, and it may be altered in clients with hepatic encephalopathy due to impaired glucose metabolism by the liver. However, lactulose does not affect the blood glucose levels directly, and it does not improve the liver's ability to regulate glucose. The nurse should monitor the fingerstick glucose to assess the risk of hypoglycemia or hyperglycemia, but not to evaluate the response to lactulose.
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