A nurse is caring for a client who has a new diagnosis of schizophrenia and a prescription for an antipsychotic medication. The nurse should recognize that which of the following indicates an adverse effect that must be reported to the provider?
The client is observed displaying a shuffling gait while walking in the hall.
The client is observed mumbling quietly while alone in the day room.
The client states, "I feel light-headed when I stand up quickly."
The client states. "Being in the sun seems to really hurt my eyes
The Correct Answer is A
Choice A reason
The client is observed displaying a shuffling gait while walking in the hall is the correct answer. The nurse should recognize that observing a shuffling gait in a client who is taking antipsychotic medication is an adverse effect that must be reported to the healthcare provider. A shuffling gait is a movement disorder known as parkinsonism, which can be a side effect of some antipsychotic medications, particularly first-generation or typical antipsychotics.
Parkinsonism includes symptoms similar to Parkinson's disease, such as a shuffling walk, muscle stiffness, tremors, and difficulty with balance and coordination. It can occur as a result of blocking dopamine receptors in the brain, leading to an imbalance in dopamine levels.
Choice B reason:
The client mumbling quietly while alone is not correct because in the day room may be related to the symptoms of schizophrenia, and it does not indicate an adverse effect of the antipsychotic medication.
Choice C reason:
The client feeling light-headed when standing up quickly is not correct and it may be related to postural hypotension, which can be a side effect of some antipsychotic medications. While it should be monitored and reported if persistent or severe, it is not as urgent as reporting a shuffling gait.
Choice D reason:
The client stating that being in the sun hurts their eyes does not necessarily indicate an adverse effect of the antipsychotic medication. It may be related to other factors or unrelated to the medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Measuring the arm circumference above the insertion site daily is appropriate. When planning care for a client scheduled to receive a peripherally inserted central catheter (PICC) in the arm, it is appropriate for the nurse to include measuring the arm circumference above the insertion site daily. This intervention is essential to monitor for any signs of complications, such as edema or swelling, which could indicate thrombosis or infiltration at the insertion site.
Choice B reason:
Administering sedation Administering sedation is not a routine intervention for a PICC insertion procedure is inappropriate. Sedation might be considered for certain procedures, but it is not typically used for PICC insertions. PICC insertions are generally performed with local anaesthesia at the insertion site.
Choice C reason:
Scheduling an MRI post procedure to verify placement An MRI is not typically used to verify the placement of a PICC. The placement of a PICC is usually confirmed using X-ray or other imaging methods that can visualize the catheter's location within the central veins. Post-procedure verification of PICC placement is essential to ensure proper positioning and to prevent complications.
Choice D reason:
Using gauze to secure an arm board to the involved extremity Using gauze to secure an arm board to the involved extremity is not a common practice for securing a PICC. After a PICC insertion, a securement device specifically designed for PICCs is typically used to secure the catheter in place and prevent movement.
Correct Answer is D
Explanation
The correct answer is choice D. Avoid using nail polish remover around the client. Nail polish remover contains acetone, which is a flammable substance that can ignite in the presence of oxygen.
Using nail polish remover around the client can increase the risk of fire and burn injuries.
Choice A is wrong because synthetic fabrics can generate static electricity, which can also cause sparks and ignite oxygen.
The client’s bedding should be made of cotton or wool, which are natural fabrics that do not produce static electricity.
Choice B is wrong because petroleum jelly is a petroleum-based product that can react with oxygen and cause skin irritation or burns.
The client should use water-based moisturizers to soothe the mucous membranes.
Choice C is wrong because alcohol-based cleaning products are also flammable and can cause fires or explosions when exposed to oxygen.
The client should use mild soap and water to clean the equipment, and follow the manufacturer’s instructions for maintenance.
Some general safety tips for home oxygen therapy are:
- Keep away from heat and flame, such as candles, matches, lighters, stoves, fireplaces, etc.
- Do not smoke or allow others to smoke near the oxygen source
- Do not use aerosols, vapor rubs, oils, or other products that contain flammable substances near the oxygen source
- Store oxygen tanks or cylinders in a well-ventilated area away from direct sunlight and heat sources
- Secure oxygen tanks or cylinders to prevent them from falling or rolling
- Use the exact rate of oxygen prescribed by the doctor for each activity
- Check the oxygen gauge or level regularly and call the medical supply company when it is low
- Use a humidifier bottle if prescribed by the doctor to prevent dryness of the mucous membranes
- Change the nasal cannula, mask, and tubing as instructed by the medical supply company to prevent
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