A client with psychosis who is receiving an antipsychotic medication is continuously rubbing the back of the neck. Which nursing intervention is best for the nurse to implement?
Obtain an extra pillow for the client to use at night.
Provide the client with a heating pad to place around the neck.
Give PRN prescription for benztropine.
Obtain a prescription for physical therapy services.
The Correct Answer is C
Continuous rubbing of the back of the neck can be a side effect of antipsychotic medication, known as acute dystonia. Benztropine is an anticholinergic medication that can effectively treat acute dystonia. Therefore, the nurse should give a PRN prescription for benztropine to relieve the client's discomfort. Options a, b, and d do not address the underlying issue of acute dystonia and are not the best interventions for this particular situation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The client is experiencing syncope (fainting) due to a drop in blood pressure to 70/40 mm Hg, which is too low. This suggests that the client's blood pressure medications are reducing their blood pressure too much, resulting in hypotension. The rationale for the nurse's decision to hold the client's scheduled antihypertensive medications is to prevent further hypotension and allow the client's blood pressure to stabilize at a safer level.
Option a is incorrect because diuresis (increased urine output) is not a likely cause of the client's hypotension.
Option b is incorrect because the client's symptoms suggest hypotension due to reduced blood pressure, rather than drug toxicity.
Option c is incorrect because the antagonistic interaction among blood pressure medications would result in reduced effectiveness but would not necessarily cause hypotension.
Correct Answer is D
Explanation
Guaifenesin is an expectorant that helps to loosen and thin mucus in the airways, making it easier to cough up. It is commonly used to manage symptoms of a chronic productive cough in conditions such as COPD.
Salmeterol and Tiotropium are both bronchodilators that help to open up the airways and improve breathing in COPD, but they are not specifically indicated for managing a chronic productive cough.
Prednisone is a corticosteroid that can help reduce inflammation in the airways and improve breathing in COPD exacerbations, but it is not typically used for managing a chronic productive cough.
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