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.

Answer and Explanation

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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Correct Answer is A

Explanation

Gentamicin sulfate is an aminoglycoside antibiotic that can cause ototoxicity, which is damage to the inner ear leading to hearing loss or balance problems. Therefore, a decrease in hearing is an indication that the client may be experiencing an adverse eﬀect of gentamicin.

Option b, decreased blood urea nitrogen, is not an adverse eﬀect of gentamicin, but it may indicate improvement in kidney function, which can be a positive outcome of treatment.

Option c, a white blood cell count of 6,000/mm3 (6x109/L), is within the normal range and is not necessarily an adverse eﬀect of gentamicin.

Option d, photophobia, is not a common adverse eﬀect of gentamicin and may indicate a diﬀerent condition or medication eﬀect.

A. Avoid crowds to help prevent acquiring infections. B. Wear protective padding to protect from bruising if a fall occurs. C. Take measures to avoid dehydration and over-heating. D. Keep skin and eyes covered to protect from sun injury.

Correct Answer is C

Explanation

Oxybutynin is a medicine used to treat symptoms of an overactive bladder. One of the side eﬀects of oxybutynin is that it can cause dry mouth, constipation, and dry skin21. These side eﬀects can increase the risk of dehydration. Additionally, oxybutynin can cause ﬂushing and heat stroke. Therefore, it is important for the client to take measures to avoid dehydration and over-heating while training for a marathon.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A male client has been receiving the antibiotic gentamicin sulfate IV piggyback every 12 hours for several days. Which observations by the nurse indicate that the client may be experiencing an adverse eﬀect of gentamicin?

Correct Answer is A

Explanation

A female client starts a new prescription, oxybutynin, for symptoms of an overactive bladder. The client tells the nurse that she is training to run in a marathon. Which instruction should the nurse emphasize?

Correct Answer is C

Explanation

The nurse is planning care for a patient with major depression who is receiving a new prescription for duloxetine. Which information is most important for the nurse to obtain?

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The nurse is preparing a client with Chronic Obstructive Pulmonary Disease (COPD) and a chronic productive cough for discharged home. Which prescribed medication should the nurse review with the client to manage this symptom?

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A client receives a new prescription for levothyroxine. Which statement made by client indicates to the nurse that the education was eﬀective?

A client who receives multiple antihypertensive multiple medications experiences syncope due to a drop in blood pressure to 70/40 mm Hg. Which is the rationale for the nurse’s decision to hold the client’s scheduled antihypertensive medications?

A client with anemia secondary to chronic kidney disease started a prescription for epoetin alfa two months ago. Which client finding best indicates that the medication is eﬀective?