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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Related Questions
Correct Answer is B
Explanation
Choice A reason: Forcibly removing the client escalates anxiety and can increase resistance. This action does not support therapeutic management of OCD.
Choice B reason: Providing a clear, respectful, and time-limited reminder supports structure and helps the client redirect behavior without confrontation. It balances therapeutic boundaries with empathy.
Choice C reason: Dismissing the client’s concern as unreasonable invalidates their experience, increasing defensiveness and mistrust. This does not support treatment goals.
Choice D reason: Avoiding the problem by redirecting the roommate fails to address the client’s compulsive behavior and disrupts the care environment.
Correct Answer is ["A","B","D"]
Explanation
Choice A reason: Planning alternate escape routes is a core part of safety planning, ensuring the victim can exit safely even if blocked.
Choice B reason: Having an emergency bag ready allows quick departure and reduces risk of having to return to the abuser’s home.
Choice C reason: Giving the abuser information about location compromises safety and places the victim at greater risk.
Choice D reason: Establishing a signal with trusted individuals ensures the victim can get help quickly if violence escalates.
Choice E reason: Encouraging firearm purchase is not an appropriate nursing intervention due to safety risks and escalation potential. Safer protective strategies should be emphasized.
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