A client with psychosis who is receiving an antipsychotic medication is continually rubbing the back of the neck. Which nursing intervention is best for the nurse to implement?
Provide the client a heating pad to place on the neck.
Obtain a prescription for physical therapy services.
Give a PRN prescription for benztropine.
Obtain an extra pillow for the client to use at night.
The Correct Answer is C
Choice A reason: Providing a heating pad to the client may provide some temporary relief, but it does not address the underlying cause of the neck discomfort, which is likely due to extrapyramidal side effects (EPS) of the antipsychotic medication.
Choice B reason: Obtaining a prescription for physical therapy services may be beneficial for the client's overall health and well-being, but it is not the best intervention for the acute problem of neck discomfort. Physical therapy may also require a referral and a waiting period, which would delay the relief for the client.
Choice C reason: Giving a PRN prescription for benztropine is the best intervention for the nurse to implement, as benztropine is an anticholinergic medication that can counteract the EPS of the antipsychotic medication. Benztropine can reduce the muscle stiffness and spasms that cause the neck discomfort.
Choice D reason: Obtaining an extra pillow for the client to use at night may help the client sleep better, but it does not address the neck discomfort during the day. It also does not treat the EPS of the antipsychotic medication, which may worsen over time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Lorazepam is a benzodiazepine that is used to treat anxiety, insomnia, and seizures. It is metabolized by the liver and does not have a significant effect on the kidneys. The nurse should monitor the client for signs of sedation, respiratory depression, and dependence.
Choice B reason: Digoxin is a cardiac glycoside that is used to treat heart failure and arrhythmias. It is eliminated by the kidneys and can cause toxicity if the renal function is impaired. The nurse should monitor the client's serum digoxin level, heart rate, and rhythm, and signs of toxicity, such as nausea, vomiting, visual disturbances, and confusion.
Choice C reason: Sucralfate is a mucosal protectant that is used to treat peptic ulcer disease. It forms a protective barrier over the ulcer and does not get absorbed into the bloodstream. It does not affect the kidneys and has few side effects. The nurse should monitor the client's symptoms and advise them to take the medication on an empty stomach.
Choice D reason: Vancomycin is an antibiotic that is used to treat serious infections caused by gram-positive bacteria. It is nephrotoxic and can cause AKI, especially in high doses or prolonged use. The nurse should monitor the client's serum vancomycin level, renal function tests, urine output, and signs of AKI, such as oliguria, edema, and electrolyte imbalances.
Correct Answer is C
Explanation
Choice A reason: Providing a heating pad to the client may provide some temporary relief, but it does not address the underlying cause of the neck discomfort, which is likely due to extrapyramidal side effects (EPS) of the antipsychotic medication.
Choice B reason: Obtaining a prescription for physical therapy services may be beneficial for the client's overall health and well-being, but it is not the best intervention for the acute problem of neck discomfort. Physical therapy may also require a referral and a waiting period, which would delay the relief for the client.
Choice C reason: Giving a PRN prescription for benztropine is the best intervention for the nurse to implement, as benztropine is an anticholinergic medication that can counteract the EPS of the antipsychotic medication. Benztropine can reduce the muscle stiffness and spasms that cause the neck discomfort.
Choice D reason: Obtaining an extra pillow for the client to use at night may help the client sleep better, but it does not address the neck discomfort during the day. It also does not treat the EPS of the antipsychotic medication, which may worsen over time.
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