When administering an antipsychotic medication to a client diagnosed with schizophrenia, which action would be most appropriate for the nurse to include in the client's plan of care? Select all that apply.

Monitoring the client for neuroleptic malignant syndrome for up to 2 months after initiating the drug.

Encouraging the client to report signs of diabetes, such as increased thirst, hunger, and urination.

Advising the client to report weight gain and skin rashes to the health care provider immediately.

Using the Abnormal Involuntary Movement Scale (AIMS) to assess for neurologic adverse effects.

Administering the medication subcutaneously when the client is unable to swallow effectively.

Answer and Explanation

Correct Answer : A,B,C,D

A. Monitoring the client for neuroleptic malignant syndrome for up to 2 months after initiating the drug. Neuroleptic malignant syndrome (NMS) is a rare but serious adverse effect of antipsychotic medications. Monitoring for NMS, especially during the first few months of treatment, is crucial.

B. Encouraging the client to report signs of diabetes, such as increased thirst, hunger, and urination. Some antipsychotics, particularly second-generation antipsychotics, are associated with an increased risk of metabolic syndrome, including diabetes. Clients should be educated to report symptoms suggestive of hyperglycemia.

C. Advising the client to report weight gain and skin rashes to the health care provider immediately. Weight gain is a common side effect, particularly with second-generation antipsychotics. Skin rashes could indicate an allergic reaction, including serious conditions like Stevens-Johnson syndrome, requiring immediate medical attention.

D. Using the Abnormal Involuntary Movement Scale (AIMS) to assess for neurologic adverse effects. The AIMS scale is used to assess for tardive dyskinesia and other extrapyramidal symptoms, which are potential adverse effects of antipsychotic medications.

E. Administering the medication subcutaneously when the client is unable to swallow effectively. Antipsychotic medications are generally not administered subcutaneously. If a client cannot swallow, an alternative route such as intramuscular injection or an orally disintegrating tablet might be used.

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Correct Answer is D

Explanation

A. Hypokalemia or hyponatremia: While electrolyte imbalances are important, they are not the most immediate threat in the context of a heroin overdose.

B. Acute gastrointestinal bleed: An acute gastrointestinal bleed is not a primary concern with heroin overdose. It is not the most acute threat in this scenario.

C. Increased intracranial pressure: Increased intracranial pressure is not directly related to heroin overdose. The most pressing issue is related to the effects of the overdose.

D. Respiratory depression: Heroin overdose commonly leads to respiratory depression, which is the most immediate and life-threatening condition. Addressing respiratory depression is crucial for patient survival.

A. Normal pessimism of the elderly. B. A cry for sympathy. C. Normal grieving. D. Evidence of high suicide potential.

Correct Answer is D

Explanation

A. Normal pessimism of the elderly: This statement downplays the seriousness of the client’s feelings. Although some elderly individuals may experience sadness, these statements suggest a deeper issue that should not be considered normal.

B. A cry for sympathy: This response dismisses the client's feelings as attention-seeking, which could lead to missing a serious issue, such as depression or suicidal ideation.

C. Normal grieving: While grief can lead to feelings of sadness, the statements indicate a broader sense of hopelessness and worthlessness, which goes beyond normal grieving.

D. Evidence of high suicide potential: The client’s statements suggest feelings of hopelessness and despair, which are red flags for suicide risk, especially in elderly clients. This requires immediate assessment and intervention.

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When administering an antipsychotic medication to a client diagnosed with schizophrenia, which action would be most appropriate for the nurse to include in the client's plan of care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Paramedics have brought a patient to the emergency department with a suspected heroin overdose. The nurse should recognize that the patient's most acute threat to health at this time is:

Correct Answer is D

Explanation

A client, age 79 years, tells the home visiting nurse, "I've been feeling down for the last few days. I don't have much to live for. My family and friends are all dead. My money's running out, and my health is failing." The nurse should assess this as:

Correct Answer is D

Explanation

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