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?

The correct answer is C. Instruct the client to request assistance when ambulating to the bathroom.

Choice A reason:

Advise the client that the medication should start to work in about 30 minutes.

While it is important to inform the client about the onset of action of the medication, this is not the highest priority. Codeine, an opioid, can cause dizziness and sedation, which increases the risk of falls. Therefore, safety measures take precedence over informing the client about the medication’s onset time.

Choice B reason:

Administer a stool softener/laxative at the same time as the analgesic.

Opioids like codeine can cause constipation, so administering a stool softener or laxative is a good practice. However, this action is not the highest priority when considering the immediate safety of the client. Ensuring the client’s safety from potential falls due to dizziness or sedation is more urgent.

Choice C reason:

Instruct the client to request assistance when ambulating to the bathroom.

This is the correct answer because codeine can cause dizziness, sedation, and orthostatic hypotension, increasing the risk of falls. Ensuring the client requests assistance when moving can prevent potential injuries, making it the highest priority nursing action.

Choice D reason:

Tell the client to notify the nurse if the pain is not relieved.

While it is important for the client to communicate about the effectiveness of pain relief, this is not the highest priority. The immediate concern is the client’s safety due to the sedative effects of codeine. Therefore, preventing falls and injuries takes precedence.

Open-angle glaucoma is a chronic eye condition that can cause irreversible damage to the optic nerve, leading to vision loss or blindness. The primary goal of treatment is to lower and control the intraocular pressure (IOP) to prevent further damage. Eye drops are often prescribed to reduce the IOP and are typically used for long-term control of normal eye pressure, even if the pressure has been reduced to a safe level.

Options a, c, and d are incorrect because they do not reflect the long-term management of open-angle glaucoma.

While reducing excess pressure may be a goal of treatment, it is not a guarantee that the eye drops will be discontinued once the pressure is normalized.

Likewise, restoring a smaller angle or managing pain and swelling may be secondary goals but are not the primary purpose of using eye drops in open-angle glaucoma