The nurse is teaching a client about lorazepam. The nurse should instruct the client to expect which of the following side effects?

The correct answer is a, b.

Choice A Reason:

The statement “Organize clinical observations” is correct. One of the primary functions of the Mental Status Exam (MSE) is to systematically organize clinical observations. This includes assessing the client’s appearance, behavior, mood, and cognitive functions. By organizing these observations, healthcare providers can create a comprehensive picture of the client’s current mental state, which is crucial for diagnosis and treatment planning.

Choice B Reason:

The statement “Obtain information about the client’s medical history” is correct. The MSE often involves gathering detailed information about the client’s medical history, including past mental health issues, treatments, and any relevant medical conditions. This information helps in understanding the client’s baseline mental status and identifying any changes or abnormalities. It also aids in creating an effective treatment plan tailored to the client’s specific needs.

Choice C Reason:

The statement “Establish limit setting” is incorrect. While limit setting is an important aspect of managing certain mental health conditions, it is not a primary function of the MSE. Limit setting typically involves establishing boundaries and rules to manage behaviors, which is more relevant in therapeutic settings rather than during the assessment phase. The MSE focuses on evaluating the client’s current mental state rather than setting behavioral limits.

Choice D Reason:

The statement “Determine the client’s IQ” is incorrect. The MSE is not designed to measure a client’s intelligence quotient (IQ)4. Instead, it assesses cognitive functions such as memory, attention, and orientation. IQ tests are specialized assessments that require specific tools and are conducted separately from the MSE. The MSE provides a general overview of cognitive functioning but does not quantify intelligence.

Choice A Reason:

Pseudo-Parkinsonian side effects, also known as drug-induced parkinsonism, can occur with the use of antipsychotic medications like haloperidol. These side effects include symptoms such as rigidity, bradykinesia, tremor, and postural instability. However, the description of the client’s neck arched sharply backward is more indicative of an acute dystonic reaction rather than pseudo-Parkinsonian side effects. Pseudo-Parkinsonian symptoms typically develop more gradually and do not present with such dramatic posturing.

Choice B Reason:

While some side effects of haloperidol can be temporary and may disappear after several days, the acute dystonic reaction described in the scenario requires immediate intervention. Acute dystonic reactions are characterized by sudden, severe muscle contractions that can be painful and potentially dangerous if they involve the airway. Therefore, it is crucial to address this reaction promptly rather than waiting for it to resolve on its own.

Choice C Reason:

Increasing the dosage of haloperidol in response to the described symptoms would likely exacerbate the situation. The client’s symptoms are not indicative of worsening psychotic behavior but rather an adverse reaction to the medication. Increasing the dosage could lead to more severe side effects and complications. The appropriate response is to treat the acute dystonic reaction and reassess the medication regimen.

Choice D Reason:

An acute dystonic reaction is a known side effect of antipsychotic medications like haloperidol. It involves sudden, severe muscle contractions, often affecting the neck, face, and back. This reaction can be distressing and requires immediate treatment with anticholinergic medications such as benztropine or diphenhydramine. Prompt intervention can relieve the symptoms and prevent further complications.