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.
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Correct Answer is C
Explanation
This is because coarctation of the aorta is a congenital condition where the aorta is narrow, usually in the area where the ductus arteriosus inserts. This causes a decrease in blood flow to the lower body, resulting in weak or absent pulses in the femoral arteries.
The other choices are incorrect for the following reasons:
- Choice A, frequent nosebleeds, is not a typical sign of coarctation of the aorta.
Nosebleeds can be caused by many factors, such as dry air, allergies, trauma, or bleeding disorders.
- Choice B, upper extremity hypotension, is also not a common finding in coarctation of the aorta. In fact, patients with this condition may have high blood pressure in the upper extremities due to the increased resistance of the narrowed aorta.
- Choice D, increased intracranial pressure, is not directly related to coarctation of the aorta.
Increased intracranial pressure can be caused by various conditions that affect the brain, such as head injury, stroke, infection, or tumor.
Normal ranges for blood pressure and pulse vary depending on age, sex, and health status.
However, some general guidelines are:
- Blood pressure: less than 120/80 mmHg for adults; less than 95/65 mmHg for infants.
- Pulse: 60 to 100 beats per minute for adults; 100 to 160 beats per minute for infants.
Correct Answer is A
Explanation
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.
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