The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention?
Shuffling gait and stooped posture.
Rocks back and forth in the chair.
Muscle spasms of the back and neck.
Lip smacking and frequent eye blinking.
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Increased fatigue is a common side effect of many medications and illnesses but is not as immediately concerning.
B. Watery diarrhea can indicate a serious side effect such as Clostridium difficile-associated diarrhea, which requires prompt medical attention.
C. Nausea and headache are common side effects but are generally not urgent.
D. Yellow-tinged sputum can indicate infection but is not as critical as the potential for a serious gastrointestinal issue.
Correct Answer is D
Explanation
A. Food contamination from flood waters can lead to gastrointestinal issues, but in disaster scenarios, contaminated drinking water is a more common source of widespread diarrhea.
B. Close living quarters at evacuation centers can contribute to the spread of infectious diseases, but they are less likely to be the primary source of contamination compared to drinking water.
C. Nosocomial transmission in the medical area is possible but less likely to be the primary source of widespread diarrhea among disaster victims.
D. Drinking water contaminated by sewage is a common and significant source of gastrointestinal infections, especially in disaster scenarios where infrastructure may be compromised.
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