Exhibits

Click to highlight the findings that would indicate the client's condition has improved.

The client presents for his 30 day follow up appointment. The client reports not feeling dizzy when he gets up to ambulate. He reports his heart races at times when he goes to the bathroom. The client reports 1 episode of incontinence in the last 30 days. Gets up 1 to 2 times a night to void. Has noticed increased swelling of his testicles. Even with the penile implant, the client is unable to have penetrative intercourse with his partner. The client is experiencing body aches daily.

A. Shuffling gait and stooped posture are common side effects of antipsychotic medications and may require intervention but are not immediately dangerous.

B. Rocking back and forth in the chair can be a self-soothing behavior in individuals with schizophrenia and usually does not require immediate intervention.

C. Muscle spasms of the back and neck (dystonia) can be a sign of a serious side effect of antipsychotic medications known as extrapyramidal symptoms and require immediate intervention to prevent complications such as airway obstruction.

D. Lip smacking and frequent eye blinking can indicate tardive dyskinesia, a long-term side effect of antipsychotic medication, but it is not an immediate emergency.

A. Attach the client to a cardiorespiratory monitor to measure the respiratory rate: The respiratory rate is within the normal range and does not require continuous monitoring at this stage unless other symptoms suggest deterioration.

B. Assure that the blood pressure cuff is the right size: The blood pressure is within normal limits and does not indicate an issue with the cuff size at this moment.

C. Alert the healthcare provider once the abnormal finding is confirmed: A temperature of 102.1° F (38.9° C) is a significant fever and could indicate worsening infection or an adverse reaction to the medication. Alerting the healthcare provider is essential for prompt evaluation and treatment adjustment.

D. Retake the temperature orally: Confirming the elevated temperature with a retake is crucial for accuracy. Temperature readings can sometimes be affected by factors like improper thermometer use or external influences.

E. Reassess the blood pressure: Blood pressure readings are stable and not indicative of any immediate issue requiring reassessment.

F. Measure the heart rate for a full 60 seconds: The heart rate of 62 beats/minute is on the lower side of normal, and measuring for a full minute will provide a more accurate assessment of the client’s heart rate and detect any irregularities.