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 B
Explanation
Choice A reason: Sedative medications may be used in severe cases, but immediate nursing care focuses on nonpharmacologic interventions to ensure safety and reduce stimulation. Medication is not the first-line action.
Choice B reason: Providing a calm environment with reduced external stimuli while encouraging expression of feelings helps the client regain control and decreases anxiety during a panic episode. This is the most appropriate nursing intervention.
Choice C reason: Detailed problem-solving requires higher-level cognitive functioning, which is impaired during a panic attack. Attempting this intervention may increase the client’s distress.
Choice D reason: Allowing expression without guidance offers no therapeutic support and may leave the client overwhelmed by panic symptoms, prolonging the episode.
Correct Answer is D
Explanation
Choice A reason: Schizotypal disorder is characterized by eccentric behaviors, odd beliefs, and perceptual distortions. While social difficulties are common, the primary feature is not a lack of interest in relationships but unusual thought patterns and behaviors.
Choice B reason: Paranoid personality disorder involves pervasive distrust and suspicion of others. Clients often avoid relationships due to fear of being exploited, not because of a lack of interest in intimacy.
Choice C reason: Antisocial personality disorder is defined by disregard for others’ rights, impulsivity, and rule-breaking behaviors, not by withdrawal from sexual or social relationships.
Choice D reason: Schizoid disorder is marked by detachment from social relationships and a limited range of emotional expression, including little to no interest in sexual activity or partnerships, making this the best match.
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