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 C

Explanation

Tamsulosin is an alpha-1 adrenergic receptor blocker that is commonly used to treat benign prostatic hyperplasia (BPH). One of the potential adverse reactions of tamsulosin is hypotension, which can be manifested as dizziness, lightheadedness, and fainting. Therefore, monitoring blood pressure is a crucial intervention for clients receiving tamsulosin.

Assessing urine output (option a) and performing a bladder scan (option b) may be appropriate interventions for clients with urinary retention or other urinary tract issues, but they are not specific to monitoring adverse reactions to tamsulosin.

Obtaining daily weights (option d) may be useful for monitoring ﬂuid balance in some clients, but it is not directly related to adverse reactions to tamsulosin.

A. Use stool softener as needed. B. Avoid ingestion of alcohol. C. Discontinue when spasms cease. D. Take medication with meals.

Correct Answer is C

Explanation

Baclofen is a muscle relaxant medication used to treat muscle spasticity, which is a condition that causes muscles to become stiﬀ and rigid. It works by reducing the activity of nerves in the brain and spinal cord that cause muscle spasms.

Option a, using stool softener as needed, is appropriate because baclofen can cause constipation as a side eﬀect.

Option b, avoiding ingestion of alcohol, is also appropriate because alcohol can increase the sedative eﬀects of baclofen and cause drowsiness or dizziness.

Option d, taking medication with meals, is recommended because it can help reduce stomach upset and nausea that may occur as a side eﬀect of the medication.

Option c, discontinuing the medication when spasms cease, is incorrect because muscle spasticity is a chronic condition, and baclofen is used to manage symptoms over a prolonged period. Discontinuing the medication abruptly can cause withdrawal symptoms and exacerbate the spasticity. Therefore, the nurse should educate the client to take the medication as prescribed by the healthcare provider and not discontinue it without medical advice.

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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 with benign prostatic receives a new prescription of tamsulosin. Which intervention should the nurse use to monitor an adverse reaction?

Correct Answer is C

Explanation

A client with muscle spasticity receives a prescription for baclofen. Which information provided by the client requires additional instruction by the nurse?

Correct Answer is C

Explanation

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