The client with schizophrenia taking antipsychotic medication is conversing with the nurse when the eye's roll back in a locked position and their jaw presents to be locked in one position. Which is the priority action by the nurse?

Place the client on seizure precautions.

Notify the physician

Administer Benadryl/diphenhydramine IM immediately as prescribed

Advocate for a decrease in the antipsychotic medication

Answer and Explanation

The Correct Answer is C

A. Place the client on seizure precautions: The presentation of eyes rolling back and jaw locking is consistent with an acute dystonic reaction, not seizure activity. Seizure precautions would not address the immediate pathophysiologic cause.

B. Notify the physician: Informing the provider is important, but it is not the priority. Acute dystonia is a medical emergency that requires rapid intervention to relieve painful and potentially dangerous muscle contractions before further communication with the provider.

C. Administer Benadryl/diphenhydramine IM immediately as prescribed: Diphenhydramine, an antihistamine with anticholinergic properties, rapidly relieves acute dystonia caused by antipsychotic medications. Prompt treatment prevents airway compromise and reduces client distress.

D. Advocate for a decrease in the antipsychotic medication: Medication adjustment may be needed long-term, but reducing the antipsychotic dosage does not resolve the immediate dystonic crisis. The client first requires urgent pharmacologic intervention.

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Correct Answer is D

Explanation

A. "I can get a supply of the medication for 60 days at a time": Clozapine requires frequent blood monitoring because of the risk of agranulocytosis. Clients are usually dispensed only a 1–2 week supply at a time depending on lab results.

B. "I may have a fatal response if I go outside and develop a rash": Clozapine is not associated with fatal skin reactions from sunlight exposure, its most critical concern is blood dyscrasias such as agranulocytosis.

C. "I need to have monthly cytokines tests for up to a year": Clients on clozapine require weekly complete blood counts (CBCs) for the first 6 months, then every 2 weeks for the next 6 months, and monthly only after a year if stable. Cytokine testing is not part of clozapine monitoring.

D. "I should call the health care provider if I develop a sore throat and fever": Sore throat and fever may signal agranulocytosis or severe neutropenia, which are potentially life-threatening side effects of clozapine. Prompt reporting ensures early intervention.

A. HIV targets macrophages, resulting in decreased phagocytic activity and antigen presentation B. HIV primarily targets T lymphocytes, leading to decreased production of antibodies. C. HIV infects B lymphocytes, impairing the body's ability to recognize and respond to pathogens. D. HIV infects CD4+ T lymphocytes, causing progressive depletion of these cells and weakening the immune system.

Correct Answer is D

Explanation

A. HIV targets macrophages, resulting in decreased phagocytic activity and antigen presentation: HIV can infect macrophages, but this is not the primary mechanism of immune suppression. Macrophage dysfunction contributes to immunodeficiency but is secondary to CD4+ T-cell depletion.

B. HIV primarily targets T lymphocytes, leading to decreased production of antibodies: HIV affects T lymphocytes, but the main consequence is the loss of CD4+ helper cells, which indirectly affects B-cell function. Antibody production is impaired, but the central issue is T-cell depletion.

C. HIV infects B lymphocytes, impairing the body's ability to recognize and respond to pathogens: HIV does not directly infect B cells. B-cell dysfunction occurs secondary to the loss of helper T-cell support, leading to inadequate immune responses.

D. HIV infects CD4+ T lymphocytes, causing progressive depletion of these cells and weakening the immune system: The virus targets CD4+ T-helper cells, gradually destroying them, which impairs both cell-mediated and humoral immunity, leaving the client susceptible to opportunistic infections and AIDS-related complications.

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The client with schizophrenia taking antipsychotic medication is conversing with the nurse when the eye's roll back in a locked position and their jaw presents to be locked in one position. Which is the priority action by the nurse?

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