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 D
Explanation
Choice A reason: Focusing only on medications neglects the interpersonal development central to Peplau’s model. The orientation phase emphasizes relationship building, not task-centered care.
Choice B reason: Allowing expression without structure or guidance does not fulfill the orientation phase, which requires the nurse to actively build trust and clarify roles.
Choice C reason: Excessive distance prevents rapport, which is essential in the orientation phase where the foundation for a therapeutic relationship must be established.
Choice D reason: Establishing trust, being consistent, and clarifying client expectations define the orientation phase of Peplau’s theory. This phase sets the groundwork for collaboration and progress in treatment.
Correct Answer is A
Explanation
Choice A reason: Nurses have a duty to protect potential victims from harm. Breaking confidentiality is justified to warn the intended victim and involve the healthcare team, consistent with the Tarasoff duty to warn principle.
Choice B reason: Warning the victim without involving the treatment team ignores the collaborative care process and may compromise safety planning.
Choice C reason: Waiting to act places the potential victim at risk and disregards the ethical duty to prevent harm.
Choice D reason: Maintaining confidentiality in this situation endangers others and violates the ethical principle of nonmaleficence.
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