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 B
Explanation
The correct answer is B.
Previous violent behavior. According to the web search results, this is the best predictor of future violence among the given risk factors.
Other risk factors include past history of aggression, poor impulse control, and violence. Comorbidity that leads to acts of violence (psychotic delusions, command hallucinations, violent angry reactions with cognitive disorders).
Choice A is wrong because a history of being in prison is not a direct cause of violence, but rather a possible consequence of it.
Choice C is wrong because male gender is not a sufficient factor to predict violence, as there are many other variables involved. Choice D is wrong because experiencing delusions is not necessarily associated with violence, unless they are of a paranoid or persecutory nature.
Normal ranges for violence risk assessment are not standardized, but some tools that can be used include the Historical Clinical Risk Management-20 (HCR-20), the Violence Risk Appraisal Guide (VRAG), and the Psychopathy Checklist-Revised (PCL-R). These tools use different scales and criteria to evaluate the likelihood of violent behavior in individuals.
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale: While additional staff may be needed, the primary focus during a mass casualty event is triage and immediate care. Choice B rationale: Media relations are important, but the nurse's priority is direct patient care. Choice C rationale: Assessing incoming clients and determining their medical needs is crucial for prioritizing care and allocating resources effectively. Choice D rationale: Discharging stable clients may be necessary in extreme circumstances, but it is not the immediate priority. The focus should be on providing care to the influx of injured patients.
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