Which action should a nurse take when a client with a history of psychosis experiences sudden severe agitation after medication administration?

Engage the client in a group therapy session.

Recommend rest and monitor vital signs.

Administer prescribed benzodiazepines.

Instruct the client to use deep breathing exercises.

Answer and Explanation

The Correct Answer is C

Choice A reason: Engaging a severely agitated client in a group therapy session is contraindicated and potentially dangerous. High levels of stimulation and the presence of other patients can exacerbate the client's psychosis and agitation, leading to an increased risk of physical aggression or injury to the client and others in the therapeutic environment.

Choice B reason: While monitoring vital signs is an important nursing responsibility, recommending rest alone is insufficient for a client experiencing sudden severe agitation. Agitation in a psychotic client often requires active pharmacological intervention to ensure safety and prevent the escalation of behavioral dysregulation that could lead to physical restraint or seclusion.

Choice C reason: Administering prescribed benzodiazepines, such as lorazepam, is the standard medical intervention for acute agitation. These medications enhance the effect of the neurotransmitter gamma-aminobutyric acid (GABA) at the GABA-A receptor, resulting in rapid anxiolysis and sedation. This helps to stabilize the client quickly and reduce the risk of violent outbursts.

Choice D reason: Instructing a client to use deep breathing exercises is a useful technique for mild anxiety but is generally ineffective during a state of severe, sudden agitation or active psychosis. The client’s cognitive processing and ability to follow complex verbal instructions are significantly impaired during an acute episode, necessitating a more direct pharmacological approach.

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Correct Answer is D

Explanation

Choice A reason: Increasing the dose of risperidone would likely exacerbate pseudoparkinsonism. These symptoms are caused by the blockade of dopamine D2 receptors in the nigrostriatal pathway; adding more of the offending agent would worsen the imbalance between dopamine and acetylcholine, leading to increased rigidity and tremors.

Choice B reason: While education is important for long-term management, it is not the priority action when a client is suffering from acute, distressing extrapyramidal symptoms. The immediate goal is to alleviate the physical discomfort and functional impairment caused by the drug-induced parkinsonian symptoms through pharmacological intervention.

Choice C reason: Monitoring symptoms over time is insufficient because pseudoparkinsonism typically does not resolve without intervention as long as the antipsychotic remains at the same dose. Delaying treatment can lead to decreased medication adherence and prolonged physical distress, which may negatively impact the client's overall psychiatric prognosis.

Choice D reason: Pseudoparkinsonism results from a relative deficiency of dopamine and an excess of cholinergic activity. Administering an anticholinergic medication, such as benztropine or trihexyphenidyl, restores the chemical balance in the basal ganglia, rapidly relieving the muscle stiffness, shuffling gait, and tremors associated with the antipsychotic medication.

A. Panic disorder B. Generalized anxiety disorder C. Separation anxiety disorder D. Agoraphobia

Correct Answer is B

Explanation

Choice A reason: Panic disorder is characterized by recurrent, unexpected panic attacks, which are sudden surges of intense fear or discomfort. It is not defined by a "variety of circumstances" or constant worry, but rather by the acute physiological "fight or flight" response and the subsequent fear of future attacks.

Choice B reason: Generalized anxiety disorder (GAD) is defined by the DSM-5 as excessive anxiety and worry about a number of events or activities (such as work or school performance) for at least 6 months. The client’s inability to control this pervasive worry is the hallmark feature of GAD.

Choice C reason: Separation anxiety disorder involves excessive fear or anxiety concerning separation from those to whom the individual is attached. While it involves worry, the worry is specific to the loss of or harm to attachment figures, rather than a broad spectrum of various life circumstances.

Choice D reason: Agoraphobia is a disorder where an individual fears or avoids places or situations that might cause them to feel trapped, helpless, or embarrassed. This is a situational anxiety related to the environment and safety, not the generalized, free-floating worry that permeates different aspects of daily life.

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Which action should a nurse take when a client with a history of psychosis experiences sudden severe agitation after medication administration?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has been prescribed risperidone displays signs of pseudoparkinsonism. What is the priority action the nurse should take?

Correct Answer is D

Explanation

A nurse is assisting in the care of a client who is experiencing excessive anxiety and worry in response to a variety of circumstances, and is unable to control their sense of worry. The nurse should identity that these manifestations indicate which of the following?

Correct Answer is B

Explanation

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