The nurse is assessing a client diagnosed with schizophrenia, who has been prescribed Haloperidol for the past year. On assessment, the nurse notices that the client is demonstrating bizarre facial and tongue movements. What is the priority nursing intervention?

Administer the 6mg Benztropine orally with a full glass of water on an empty stomach.

Ask the healthcare provider to increase the dose of Haloperidol to assist with the side effect.

Hold the dose of Haloperidol and notify the healthcare provider.

Explain to the client that the side effects should diminish in one to two weeks.

Answer and Explanation

The Correct Answer is C

a. Administer the 6mg Benztropine orally with a full glass of water on an empty stomach: Benztropine is an anticholinergic medication used to manage the extrapyramidal side effects (EPS) of antipsychotics. However, it's important to consult the healthcare provider before administering any additional medications.
b. Ask the healthcare provider to increase the dose of Haloperidol to assist with the side effect: Increasing the dose of Haloperidol might worsen the tardive dyskinesia symptoms.
c. Hold the dose of Haloperidol and notify the healthcare provider. (Correct) Haloperidol is an antipsychotic medication with a known side effect of tardive dyskinesia, which manifests as involuntary facial and body movements. Stopping the medication and informing the provider is crucial to determine the best course of action, which might involve dose adjustment or switching medications

d. Explain to the client that the side effects should diminish in one to two weeks: Tardive dyskinesia can be a persistent side effect, and reassurance without addressing the medication is not helpful.

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Correct Answer is A

Explanation

a. "I can see that you are upset. Let's talk about ways to resolve this." This is correct because it validates the client's feelings, encourages problem-solving, and maintains the therapeutic milieu's principles of respect and support.
b. "I'll fix this right away. You need to calm down." This response does not encourage the client’s participation in resolving the issue and does not foster the therapeutic milieu's goal of client empowerment.
c. "Let's find a way to avoid this conflict in the future." While this promotes future problem-solving, it does not address the immediate concern or validate the client's current feelings.
d. "You should bring this up during group therapy later this week." This delays addressing the client's immediate concerns and might make the client feel unheard.

A. Encourage alone time for the client in seclusion B. Assess one time for self-harm during treatment C. Discuss alternative coping strategies with the client D. Allow for unlimited discussion of physical symptoms

Correct Answer is C

Explanation

a. Encourage alone time for the client in seclusion: Encouraging alone time in seclusion may exacerbate feelings of isolation and is not typically recommended for clients with conversion disorder, who may benefit more from social support and therapeutic interventions.
b. Assess one time for self-harm during treatment: While assessing for self-harm is important, it is not specific to conversion disorder and should be part of routine nursing care for all clients, regardless of diagnosis.
c. Discuss alternative coping strategies with the client: This is correct because exploring alternative coping strategies can help the client manage stressors and symptoms associated with conversion disorder in healthier ways.
d. Allow for unlimited discussion of physical symptoms: Allowing unlimited discussion of physical symptoms may reinforce symptom focus and is not typically recommended in the treatment of conversion disorder, where the focus is on addressing underlying psychological distress.

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The nurse is assessing a client diagnosed with schizophrenia, who has been prescribed Haloperidol for the past year. On assessment, the nurse notices that the client is demonstrating bizarre facial and tongue movements. What is the priority nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with schizophrenia, on an inpatient unit, approaches a nurse, stating, "Someone took my dinner! People need to respect others, and you need to do something about this now!" Which response by the nurse is guided by the basic assumption of the therapeutic milieu?

Correct Answer is A

Explanation

A nurse is caring for a client who is diagnosed with a conversion disorder. What actions should the nurse include in the plan of care?

Correct Answer is C

Explanation

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