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 D

Explanation

Atorvastatin is a medication used to lower cholesterol levels in the blood. One of its side eﬀects is muscle damage, which can result in an increase in serum creatine phosphokinase (CK) levels. Creatine phosphokinase is an enzyme found in muscles, and when muscles are damaged, CK is released into the bloodstream. Therefore, an increased serum CK level indicates muscle damage, and the nurse should assess the client for muscle tenderness or weakness, which are symptoms of this side eﬀect. Nausea and vomiting, excessive bruising, and peripheral edema are not typically associated with atorvastatin use.

A. Administers onto the ﬂeshy outer thigh. B. Inserts the injection pen through clothing. C. Cleanses the injection pen for re-use. D. Cleans the injector pen for re-use.

Correct Answer is C

Explanation

A. Administers onto the ﬂeshy outer thigh: This is the recommended site for epinephrine auto-injection because it allows for quick absorption into the bloodstream. The outer thigh is a large muscle area, which helps in the rapid distribution of the medication.

B. Inserts the injection pen through clothing: It is generally acceptable to inject epinephrine through clothing in an emergency situation. This practice ensures that there is no delay in administering the life-saving medication, which is crucial during an anaphylactic reaction.

C. Cleanses the injection pen for re-use: Epinephrine auto-injectors are designed for single use only. Reusing the pen can lead to contamination and reduced effectiveness of the medication. It is important to dispose of the used injector properly and obtain a new one for future use.

D. Holds the pen in place after injection: Holding the pen in place for a few seconds after injection ensures that the full dose of medication is delivered. This practice helps in maximizing the effectiveness of the treatment during an anaphylactic emergency.

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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 client taking atorvastatin becomes an increased serum creatine phosphokinase (CK) level. The nurse should assess the client for the onset of which problem?

Correct Answer is D

Explanation

The home health nurse observes a client self-administering an epinephrine injection using an auto-injector pen. Which client action requires intervention by the nurse?

Correct Answer is C

Explanation

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?

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