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
The correct answer is choice A. “I can give you information about respite care if you are interested.” Respite care is a service that provides short-term inpatient care for terminally-ill patients at a professional care facility, such as a hospital, hospice inpatient care facility, or nursing home. It is meant to relieve caregiver stress and offer them rest and time away from caregiving duties. Respite care is covered by Medicare for up to five consecutive days and no more than one respite period in a single billing period.
The nurse should offer this option to the son who is experiencing sleep deprivation due to caring for his mother.
Choice B is wrong because it suggests that the son should rely on medication to cope with his situation, which may not be appropriate or effective.
Sleeping pills may have side effects or interactions with other drugs, and they do not address the underlying cause of the son’s stress and fatigue.
Choice C is wrong because it does not acknowledge the son’s need for support or assistance.
It may sound like an empty compliment or a dismissal of the son’s concerns.
The nurse should express empathy and compassion, but also provide information and resources that can help the son.
Choice D is wrong because it does not offer any solution or guidance to the son.
It may also sound like a cliché or a generalization that does not reflect the son’s unique experience.
The nurse should avoid making assumptions or judgments about the son’s feelings or situation, and instead focus on his needs and preferences.
Correct Answer is D
Explanation
The correct answer is d. Evaluate functioning of the suction device.
Choice D rationale:
- Prompt assessment of the suction device is crucial to determine if it's functioning properly.If the suction is inadequate,it can lead to gastric contents accumulating and potentially causing vomiting.
- Assessing the suction device first allows for timely interventionif it's not working correctly,preventing further complications and discomfort for the client.
Choice A rationale:
- Replacing the NG tube might be necessary if it's dislodged or blocked, but it shouldn't be the immediate action.
- Evaluating the suction device first can help determine if the NG tube itself is the issue or if the problem lies with the suction.
Choice B rationale:
- Providing oral hygiene care is important for comfort and to prevent aspiration, but it's not the priority intervention in this situation.
- Addressing the cause of the vomiting, which could be related to suction malfunction, takes precedence.
Choice C rationale:
- Administering an antiemetic might be helpful to control nausea and vomiting, but it doesn't address the underlying cause.
- Evaluating the suction device first is essential to ensure proper gastric decompression and prevent further vomiting episodes.
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