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) Returning at a later time to talk might seem considerate, but it may miss the opportunity to engage with the client in the moment. The client may benefit from having the nurse's presence and support, even if they are slow to respond.

B) Asking a different question could disrupt the process and prevent the client from expressing their feelings. It’s important to allow the client the space to answer the original question rather than shifting topics prematurely.

C) Waiting for the client to respond is the best action. This approach demonstrates patience and respect for the client's current state. By allowing time for a response, the nurse can create a supportive environment, which may help the client feel more comfortable opening up when they are ready.

D) Asking if the client heard the question might feel like an interruption or could add pressure, making the client more anxious. It’s better to give the client space to process and respond without feeling judged or rushed.

A. Show the client the unit. B. Offer medication to the client. C. Explain the nurse's role to the client D. Read to the client his rights.

Correct Answer is C

Explanation

A) Showing the client the unit can be helpful for orientation, but it may not address the client's immediate emotional state. Since the client is exhibiting paranoia and sitting quietly, they might not feel safe or ready to engage in a tour.

B) Offering medication to the client may be appropriate later, but it does not address the client's current need for safety and trust. If the client is feeling paranoid, they might be suspicious of medications offered right away.

C) Explaining the nurse's role to the client is the first and most important intervention. This helps to establish trust and reduce anxiety, as it clarifies the nurse's intentions and reassures the client that they are there to provide support. Building rapport is crucial in dealing with a client exhibiting paranoia.

D) Reading the client their rights is important but may feel overwhelming to a client who is already anxious or paranoid. It’s more effective to first build a connection and establish a sense of safety before discussing rights or other formalities.

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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?

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