The client states that he has not taken his antipsychotic drug for the past 2 weeks because it was causing sexual dysfunction. What is the nurse’s primary concern at this time?
A hypertensive crisis may occur with such abrupt withdrawal of the drug.
Significant muscle twitching may occur, increasing fall risk.
EPS symptoms such as pseudo-parkinsonism are likely to occur.
Symptoms of psychosis are likely to return.
The Correct Answer is D
When a patient abruptly stops taking an antipsychotic medication, the therapeutic dopamine blockade is lost, often leading to a rapid recurrence of hallucinations, delusions, and disorganized thinking. The nurse’s priority is to address and prevent relapse of psychosis to ensure safety.
Rationale for correct answer:
D. Symptoms of psychosis are likely to return.
Stopping antipsychotics abruptly can cause rapid reemergence or worsening of psychotic symptoms, greatly increasing the risk of self-harm or harm to others. Immediate intervention is vital to maintain mental stability.
Rationale for incorrect answer:
A. A hypertensive crisis may occur with such abrupt withdrawal of the drug.
Hypertensive crisis is mainly linked to monoamine oxidase inhibitors (MAOIs), not antipsychotics, so it is not the primary concern.
B. Significant muscle twitching may occur, increasing fall risk.
Muscle twitching is not a common withdrawal effect of antipsychotics and is less urgent than psychosis relapse.
C. EPS symptoms such as pseudo-parkinsonism are likely to occur.
Extrapyramidal symptoms are usually a side effect during ongoing therapy, not after discontinuation.
Take-home points:
- Abrupt cessation of antipsychotics can trigger psychotic relapse.
- The nurse’s priority is patient safety and symptom management.
- Hypertensive crisis is not associated with antipsychotic withdrawal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Phenothiazines, a class of first-generation antipsychotics, can cause acute dystonia early in treatment. This is a type of extrapyramidal symptom (EPS) characterized by severe, involuntary muscle spasms that may affect the neck, face, tongue, or back, and require prompt medical attention.
Rationale for correct answer:
B. Severe muscle spasms may occur early in therapy.
Acute dystonic reactions are a known early adverse effect, often appearing within hours to days of starting phenothiazines. Education should stress reporting these symptoms immediately, as they can compromise breathing or swallowing.
Rationale for incorrect answer:
A. The client may experience withdrawal and slowed activity.
Phenothiazines more commonly cause sedation, not withdrawal-like symptoms, and this is not the most urgent teaching point before discharge.
C. Tardive dyskinesia is likely early in therapy.
Tardive dyskinesia usually develops after months to years of therapy, not in the early stages.
D. Medications should be taken as prescribed to prevent adverse effects.
While adherence is important, this statement does not address a specific high-priority side effect for early treatment.
Take-home points:
- Acute dystonia can occur within the first days of phenothiazine use.
- Early recognition and reporting of muscle spasms is critical to prevent complications.
- Tardive dyskinesia develops later, not at the start of therapy.
Correct Answer is A
Explanation
When clients are treated for psychosis with first-generation antipsychotics like fluphenazine, there is an increased risk of developing extrapyramidal symptoms (EPS), particularly acute dystonia in the early stages of therapy. Nurses must anticipate prophylactic measures, including the use of specific medications to prevent or manage these symptoms, to ensure patient safety and comfort during antipsychotic treatment.
Rationale for correct answer:
A. Benztropine (Cogentin) – Anticholinergic medications like benztropine are frequently prescribed to prevent or treat EPS, including acute dystonia caused by dopamine blockade in the nigrostriatal pathway. By restoring the dopamine-acetylcholine balance in the CNS, benztropine helps reduce muscle rigidity, spasms, and abnormal postures that can occur shortly after initiating antipsychotic therapy.
Rationale for incorrect answer:
B. Diazepam (Valium) – This benzodiazepine is primarily used for anxiety, muscle relaxation, and seizure control, not for preventing EPS. While it may reduce anxiety related to symptoms, it does not address the underlying neurotransmitter imbalance that causes acute dystonia.
C. Haloperidol (Haldol) – Another first-generation antipsychotic, haloperidol can actually increase the risk of EPS, making it inappropriate for prevention. Administering it alongside fluphenazine could worsen movement-related side effects.
D. Lorazepam (Ativan) – This benzodiazepine can help relieve agitation or anxiety in psychotic patients, but it does not prevent acute dystonia because it does not correct the dopamine-acetylcholine imbalance in the basal ganglia.
Take-home points:
- Benztropine is the drug of choice for preventing acute dystonia caused by high-potency first-generation antipsychotics.
- Acute dystonia is an early-onset EPS that can occur within hours to days of starting antipsychotic therapy.
- Prevention is important because untreated acute dystonia can cause airway compromise or severe discomfort.
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