A nurse is caring for a client newly prescribed aripiprazole, a third-generation antipsychotic, for the treatment of schizophrenia. Which nursing observation would require the most immediate intervention?
The client develops muscle rigidity, high fever, and confusion.
The client reports restlessness and an inability to sit still.
The client exhibits a flat affect and decreased verbal communication.
The client expresses concern about mild weight gain.
The Correct Answer is A
Choice A reason: This presentation is consistent with neuroleptic malignant syndrome (NMS), a rare but life-threatening reaction to antipsychotics characterized by severe muscle rigidity, hyperthermia, altered mental status, and autonomic dysfunction. Immediate discontinuation of the drug and emergency treatment are required.
Choice B reason: Restlessness and inability to sit still are signs of akathisia, an extrapyramidal side effect of antipsychotics. While distressing and requiring management, it is not life-threatening compared to NMS.
Choice C reason: A flat affect and reduced speech are negative symptoms of schizophrenia and may persist despite treatment. These are concerning for quality of life but do not require urgent medical intervention.
Choice D reason: Mild weight gain is a known side effect of many antipsychotics. It should be monitored and managed with lifestyle modifications but does not represent an immediate threat.
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Correct Answer is C
Explanation
Choice A reason: Assigning leadership in a group setting may overwhelm a patient with schizoid personality disorder, as they are uncomfortable with close social interactions. This approach could increase withdrawal.
Choice B reason: Confrontation about avoidance behaviors is not therapeutic. It may heighten resistance and increase distress rather than encourage trust or engagement.
Choice C reason: Structured one-on-one interactions allow the nurse to build rapport while respecting the patient’s preference for limited emotional involvement. This is the most appropriate approach for schizoid personality disorder.
Choice D reason: Forcing daily group therapy participation may cause stress and withdrawal, as these patients are more comfortable with solitary activities. Gentle encouragement, not insistence, is better suited.
Correct Answer is C
Explanation
Choice A reason: Rationalization involves creating logical explanations to justify behavior or feelings. In this case, the client is not justifying but outright rejecting the diagnosis, so this does not apply.
Choice B reason: Regression occurs when an individual reverts to earlier developmental behaviors, such as childish actions, to cope with stress. The client is not reverting to earlier behaviors but refusing to accept reality.
Choice C reason: Denial is the refusal to accept reality or facts, blocking external events from conscious awareness. The client’s insistence that the diagnosis is a mistake demonstrates denial, making this the correct defense mechanism.
Choice D reason: Projection occurs when a person attributes their unacceptable thoughts or feelings to someone else. The client is not attributing their illness to others but rejecting its existence altogether.
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