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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Correct Answer is B
Explanation
Lactulose is a medication commonly used in the management of hepatic encephalopathy. It works by reducing the absorption of ammonia in the gut, which is a toxin that can accumulate in the blood in patients with liver dysfunction.
Monitoring serum electrolytes and ammonia levels can help the nurse evaluate the effectiveness of lactulose therapy. Elevated ammonia levels can indicate that the medication is not effectively reducing ammonia absorption and may require adjustment in dose or frequency. Additionally, monitoring electrolyte levels can help detect any imbalances that may occur because of lactulose therapy.
Fingerstick glucose levels (option A) are not relevant to evaluating the therapeutic response of lactulose in hepatic encephalopathy.
Stool color and character (option C) may be monitored to assess the side effects of lactulose, such as diarrhea, but are not the best assessments to evaluate therapeutic response.
Serum hepatic enzymes (option D) may be useful in assessing the severity of liver disease but are not the best assessment to evaluate the therapeutic response of lactulose in hepatic encephalopathy.
Correct Answer is C
Explanation
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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