A nurse is assessing for the presence of extrapyramidal side effects (EPS) in a client who is taking chlorpromazine.

Which of the following findings should the nurse recognize as EPS? (Select all that apply.).

Sexual dysfunction.

Muscle spasms of the neck.

Tremors of the hands.

Fidgeting behavior.

Blurred vision.

Answer and Explanation

Correct Answer : B,C,D

Choice A rationale:
Sexual dysfunction is not typically associated with extrapyramidal side effects (EPS). EPS are usually characterized by involuntary motor symptoms.
Choice B rationale:
Muscle spasms of the neck, also known as dystonia, are a common symptom of EPS12.
Choice C rationale:
Tremors of the hands can be a sign of EPS, often associated with drug-induced parkinsonism.
Choice D rationale:
Fidgeting behavior, or akathisia, is a common symptom of EPS. It is characterized by a feeling of restlessness and an inability to sit still.
Choice E rationale:
Blurred vision is not typically associated with EPS. It is more likely to be a side effect of the medication itself, not a symptom of EPS12.

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Correct Answer is D

Explanation

Choice A rationale:

While acknowledging the voices can be part of therapeutic communication, it’s not the first response a nurse should make.

Choice B rationale:

Telling the client that the voices are part of their illness can be helpful, but it’s not the first response a nurse should make.

Choice C rationale:

Asking about the frequency of the voices can be part of the assessment, but it’s not the first response a nurse should make.

Choice D rationale:

Asking what the voices are saying can help assess if the client is experiencing command hallucinations, which could pose a safety risk.

A. A client who has a BUN of 22 mg/dL. B. A client who has a serum potassium of 3.3 mEq/L. C. A client who has a hematocrit of 55%. D. A client who has a WBC of 2,900 cells/mm².

Correct Answer is D

Explanation

Choice A rationale:

A BUN of 22 mg/dL is slightly elevated but not a contraindication for clozapine.

Choice B rationale:

A serum potassium of 3.3 mEq/L is slightly low but not a contraindication for clozapine.

Choice C rationale:

A hematocrit of 55% is high but not a contraindication for clozapine.

Choice D rationale:

A WBC of 2,900 cells/mm² is low and can indicate agranulocytosis, a potentially life-threatening condition. Clozapine should be discontinued.

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A nurse is assessing for the presence of extrapyramidal side effects (EPS) in a client who is taking chlorpromazine. Which of the following findings should the nurse recognize as EPS? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following responses should the nurse make first?

Correct Answer is D

Explanation

A nurse is reviewing abnormal laboratory values for four clients who have schizophrenia and take clozapine. For which of the following clients should the nurse withhold the medication and notify the provider immediately to have clozapine therapy discontinued?

Correct Answer is D

Explanation

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A nurse is assessing for the presence of extrapyramidal side effects (EPS) in a client who is taking chlorpromazine.

Which of the following findings should the nurse recognize as EPS? (Select all that apply.).