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 C

Explanation

a. refuses to eat lunch. Refusal to eat lunch might indicate displeasure or upset but does not directly suggest escalating aggression.
b. requests prn medications. Requesting prn (as needed) medications typically indicates the client is aware of their distress and is seeking help, not escalating aggression.
c. is pacing around the milieu. Pacing can be a sign of increasing agitation and is often observed in clients who are escalating towards aggressive behavior. This physical activity can indicate restlessness and an inability to calm down.
d. sits in a group with their peers. Sitting in a group with peers suggests a level of social engagement and does not indicate escalating aggression.

A. interrupt the handwashing and insist the client come to meals with everyone else. B. provide the client's meals later and after the other clients have eaten. C. notify the client when it is 30 minutes before the meal so they can begin their handwashing. D. allow the client to continue as is but provide them access to the kitchen.

Correct Answer is D

Explanation

a. Interrupt the handwashing and insist the client come to meals with everyone else. Interrupting ritualistic behaviors abruptly can increase distress and is not recommended. It may also reinforce the belief that the ritual is necessary.
b. Provide the client's meals later and after the other clients have eaten. This is not appropriate as it accommodates the OCD behavior and disrupts the mealtime routine for other clients.
c. Notify the client when it is 30 minutes before the meal so they can begin their handwashing. This is not appropriate as it enables the ritualistic behavior and may lead to increased anxiety if the client feels rushed to complete their ritual.
d. Allow the client to continue as is but provide them access to the kitchen. This is correct because it respects the client's autonomy while also providing an opportunity for gradual exposure therapy, where the client can work with the nurse to gradually reduce the time spent on rituals.

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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

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Correct Answer is C

Explanation

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Explanation

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