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.

Answer and Explanation

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: Long-term memory and emotional responses are primarily associated with the limbic system, particularly the hippocampus and amygdala, not the hypothalamus.

Choice B reason: Voluntary muscle control and reflexes are coordinated by the motor cortex and spinal cord, not the hypothalamus.

Choice C reason: Processing sensory input and initiating motor responses are functions of the thalamus and cerebral cortex. The hypothalamus is not directly responsible for this role.

Choice D reason: The hypothalamus regulates homeostasis, including body temperature, thirst, fluid balance, circadian rhythms, and hormone release. A tumor compressing this area explains the patient’s symptoms.

A. Provide consistent structured rules and set firm limits on behavior. B. Use sympathy and reassurance to reduce the client’s resistance to authority. C. Allow the client flexibility in decision-making to encourage independence and self-direction. D. Develop a close, personal rapport with the client to build trust and encourage emotional expression.

Correct Answer is A

Explanation

Choice A reason: Consistent rules and firm boundaries are essential when working with individuals who display antisocial traits. Structure minimizes opportunities for manipulation and helps maintain safety and fairness on the unit.

Choice B reason: Offering sympathy and reassurance may reinforce manipulative behavior and undermine professional boundaries. It does not address the core issue of rule violation and lack of accountability.

Choice C reason: Allowing too much flexibility may increase opportunities for the client to exploit staff and disregard rules. This approach is counterproductive when dealing with manipulative behaviors.

Choice D reason: Developing a close, personal rapport risks blurring professional boundaries. Clients with these traits may exploit such relationships to gain privileges, which can disrupt treatment and unit structure.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with a tumor compressing the hypothalamus presents with fluctuating body temperature, excessive thirst, frequent urination, and disrupted sleep-wake cycles. Which of the following best explains the role of the hypothalamus related to these symptoms?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

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