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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Related Questions
Correct Answer is C
Explanation
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.
Correct Answer is D
Explanation
The client's symptoms suggest liver dysfunction, which is a known adverse effect of albendazole. Albendazole is primarily metabolized in the liver, and its use can cause liver damage in some cases. Therefore, it is essential to review liver function test results to assess the severity of liver damage and to determine if the medication should be discontinued or the dosage should be adjusted.
The renal function panel (a) measures the levels of various substances, such as creatinine and blood urea nitrogen, in the blood to assess kidney function.
The thyroid function test (b) evaluates the levels of thyroid hormones in the blood to diagnose thyroid disorders.
The basic metabolic panel (c) includes several tests that assess the levels of electrolytes, glucose, and other substances in the blood to evaluate metabolic function. However, these lab tests are not directly related to the symptoms and adverse effects associated with albendazole use
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