The nurse is completing an admission assessment of a client who is admitted to milieu. Which piece of information obtained from the client during the assessment would require immediate investigation from the nurse regarding the client’s use of complementary and alternative therapies?

Choice A Reason:

Assist the client to identify triggers or sources of stress.

This is the correct response. Before educating clients about relaxation techniques, it is essential to help them identify their specific triggers or sources of stress. Understanding what causes their stress allows for more tailored and effective relaxation strategies. This step ensures that the relaxation techniques taught are relevant and can directly address the client’s needs, leading to better outcomes in managing anxiety and stress.

Choice B Reason:

Educate the client’s family so they can be active participants in the therapy.

While involving the client’s family in therapy can be beneficial, it is not the primary action to take before educating the client about relaxation techniques. Family education can support the client’s overall treatment plan, but the initial focus should be on understanding the client’s individual stressors and needs.

Choice C Reason:

Perform a physical assessment to ensure the client is able to participate in this therapy.

Performing a physical assessment is important to ensure the client can safely participate in relaxation techniques. However, this step is secondary to identifying the client’s stress triggers. Once the triggers are identified, the nurse can then assess the client’s physical ability to engage in specific relaxation exercises.

Choice D Reason:

Obtain an order from the psychiatrist during the treatment team.

Obtaining an order from the psychiatrist may be necessary for certain interventions, but it is not typically required for teaching relaxation techniques. The nurse can independently educate clients on these techniques as part of standard nursing care for managing stress and anxiety.

Choice A Reason:

Pseudo-Parkinsonian side effects, also known as drug-induced parkinsonism, can occur with the use of antipsychotic medications like haloperidol. These side effects include symptoms such as rigidity, bradykinesia, tremor, and postural instability. However, the description of the client’s neck arched sharply backward is more indicative of an acute dystonic reaction rather than pseudo-Parkinsonian side effects. Pseudo-Parkinsonian symptoms typically develop more gradually and do not present with such dramatic posturing.

Choice B Reason:

While some side effects of haloperidol can be temporary and may disappear after several days, the acute dystonic reaction described in the scenario requires immediate intervention. Acute dystonic reactions are characterized by sudden, severe muscle contractions that can be painful and potentially dangerous if they involve the airway. Therefore, it is crucial to address this reaction promptly rather than waiting for it to resolve on its own.

Choice C Reason:

Increasing the dosage of haloperidol in response to the described symptoms would likely exacerbate the situation. The client’s symptoms are not indicative of worsening psychotic behavior but rather an adverse reaction to the medication. Increasing the dosage could lead to more severe side effects and complications. The appropriate response is to treat the acute dystonic reaction and reassess the medication regimen.

Choice D Reason:

An acute dystonic reaction is a known side effect of antipsychotic medications like haloperidol. It involves sudden, severe muscle contractions, often affecting the neck, face, and back. This reaction can be distressing and requires immediate treatment with anticholinergic medications such as benztropine or diphenhydramine. Prompt intervention can relieve the symptoms and prevent further complications.