A client with schizophrenia receives a prescription for fluphenazine. Which instruction is most important for the nurse to include when teaching the client about this drug?

Wear sunscreen when going outside to prevent effects of sun sensitivity.

Notify your healthcare provider immediately if involuntary movements develop.

Drink water frequently throughout the day as the medication increases thirst.

Check blood pressure daily and notify the healthcare provider if it increases

Answer and Explanation

The Correct Answer is B

A) Wearing sunscreen when going outside to prevent effects of sun sensitivity is important for clients taking certain antipsychotic medications, but it is not the most critical instruction. While fluphenazine can cause photosensitivity, the risk of developing involuntary movements (extrapyramidal symptoms) is a more immediate concern that could significantly affect the client’s quality of life.

B) Notifying the healthcare provider immediately if involuntary movements develop is crucial when taking fluphenazine. This medication can lead to extrapyramidal symptoms such as tardive dyskinesia or acute dystonia, which require prompt assessment and intervention to prevent long-term complications. Educating the client about these potential side effects empowers them to seek timely help.

C) Drinking water frequently throughout the day is generally good advice for overall hydration, but fluphenazine does not significantly increase thirst. While maintaining hydration is important, the focus should be on the potential for serious side effects like involuntary movements, making this instruction secondary in priority.

D) Checking blood pressure daily and notifying the healthcare provider if it increases is relevant for some medications, particularly antihypertensives or those that can cause orthostatic hypotension. However, with fluphenazine, the more critical instruction revolves around recognizing and responding to neurological side effects rather than routine blood pressure monitoring, making this less of a priority.

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Correct Answer is C

Explanation

A) Moving to a quiet area and providing peanut butter with crackers may help address the client’s nutritional needs, but it may not adequately address the client’s agitation and pacing. The immediate priority is to stabilize the client’s behavior before focusing on nutrition.

B) Encouraging the spouse to eat lunch with the client may create an opportunity for social interaction, but it might not be effective in calming the client’s agitation. If the client is already highly agitated, the spouse's presence alone may not help diffuse the situation.

C) Walking with the client to the cafeteria and staying while the client eats is the best intervention at this time. This approach allows the nurse to provide a calming presence and guidance while encouraging the client to eat. It also helps redirect the client's energy and agitation into a structured activity, promoting both physical movement and nutrition, which is crucial after several days without food.

D) Requesting a full lunch tray from the dietary department could provide a more substantial meal; however, it might not address the immediate need for calming the client. If the client remains agitated and loud, it may be challenging to ensure that they can eat peacefully, making this intervention less effective than accompanying the client directly to eat.

A. Administer a PRN analgesic to the client. B. Further assess the client's pain and vital signs. C. Ask if the client to compare this pain to the pain in the past. D. Remind the client that the symptoms are psychological in cause.

Correct Answer is B

Explanation

A) Administering a PRN analgesic may provide temporary relief but does not address the need for a comprehensive assessment of the client's condition. It is essential to understand the nature and cause of the chest pain before treating it.

B) Further assessing the client's pain and vital signs is the most appropriate action. This allows the nurse to gather important clinical information that can help determine whether the chest pain is related to a medical condition or is part of the somatic symptom disorder. A thorough assessment is critical in ensuring the client's safety and addressing any potential underlying health issues.

C) Asking the client to compare this pain to past pain can provide context but is not a priority action. The immediate focus should be on assessing the current situation rather than reflecting on past experiences.

D) Reminding the client that the symptoms are psychological in cause can be invalidating and may hinder the therapeutic relationship. It is crucial to approach the client with empathy and understanding, rather than dismissing their experience.

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A client with schizophrenia receives a prescription for fluphenazine. Which instruction is most important for the nurse to include when teaching the client about this drug?

Nursing Test Bank

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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