The nurse is assessing a client diagnosed with schizophrenia, who has been prescribed Haloperidol for the past year. On assessment, the nurse notices that the client is demonstrating bizarre facial and tongue movements. What is the priority nursing intervention?

Administer the 6mg Benztropine orally with a full glass of water on an empty stomach.

Ask the healthcare provider to increase the dose of Haloperidol to assist with the side effect.

Hold the dose of Haloperidol and notify the healthcare provider.

Explain to the client that the side effects should diminish in one to two weeks.

Answer and Explanation

The Correct Answer is C

a. Administer the 6mg Benztropine orally with a full glass of water on an empty stomach: Benztropine is an anticholinergic medication used to manage the extrapyramidal side effects (EPS) of antipsychotics. However, it's important to consult the healthcare provider before administering any additional medications.
b. Ask the healthcare provider to increase the dose of Haloperidol to assist with the side effect: Increasing the dose of Haloperidol might worsen the tardive dyskinesia symptoms.
c. Hold the dose of Haloperidol and notify the healthcare provider. (Correct) Haloperidol is an antipsychotic medication with a known side effect of tardive dyskinesia, which manifests as involuntary facial and body movements. Stopping the medication and informing the provider is crucial to determine the best course of action, which might involve dose adjustment or switching medications

d. Explain to the client that the side effects should diminish in one to two weeks: Tardive dyskinesia can be a persistent side effect, and reassurance without addressing the medication is not helpful.

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Correct Answer is D

Explanation

a. restating: Restating involves repeating the client's message to ensure understanding and encourage further communication. It is a therapeutic technique.
b. maintaining neutral responses. Neutral responses can be therapeutic as they provide nonjudgmental listening and support.
c. listening: Active listening is a fundamental therapeutic communication technique, essential for understanding the client's concerns and building rapport.
d. asking the client, "Why?" Asking "Why?" can be non-therapeutic as it may make the client feel defensive and pressured to justify their feelings or actions. It can hinder open communication.

A. observation during and after meals. B. adherence to scheduled meal times. C. trips to the local fast food restaurant for foods. D. monitoring during bathroom trips. E. weekly weight checks.

Correct Answer is ["A","B","D"]

Explanation

a. Observation during and after meals: To prevent the client from engaging in purging behaviors, such as vomiting or hiding food.

b. Adherence to scheduled meal times: To establish a regular eating pattern and help normalize the client’s relationship with food.

c. Trips to the local fast food restaurant for foods are not appropriate as they can promote unhealthy eating behaviors and do not align with the structured, therapeutic environment necessary for recovery.

d. Monitoring during bathroom trips: To prevent purging behaviors, especially right after meals when the temptation to vomit might be higher.

e. Weekly weight checks are important for monitoring progress, but daily or more frequent weight checks are often necessary to ensure safety and appropriate weight gain or stabilization.

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The nurse is assessing a client diagnosed with schizophrenia, who has been prescribed Haloperidol for the past year. On assessment, the nurse notices that the client is demonstrating bizarre facial and tongue movements. What is the priority nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse working in a mental health unit reviews therapeutic and non-therapeutic communication techniques with a student nurse. All of the following are therapeutic communication techniques except:

Correct Answer is D

Explanation

When the nurse admits a client with anorexia nervosa for treatment, the therapeutic milieu should provide: (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","D"]

Explanation

The nurse is assessing the status of a post-operative client in the PACU. The nurse should be most concerned with which assessment finding?

The nurse is giving discharge instructions to the family of a client diagnosed with a neurocognitive disorder. The nurse includes the client's family. Which statement by the family would indicate that teaching has been effective? The family states:

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What should be the priority nursing action during the orientation (introductory) phase of the nurse-client relationship?

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