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If I have a severe headache coupled with confusion, I’ll try and take a nap: Severe headache and confusion can be signs of serious side effects of risperidone, such as neuroleptic malignant syndrome (NMS) or other severe reactions. Simply trying to rest without contacting the healthcare provider could delay necessary intervention. Immediate medical attention is recommended for these symptoms.

If I promptly stop the medication if I have difficulty sleeping: Discontinuing risperidone without consulting a healthcare provider could lead to withdrawal effects or worsen symptoms. Difficulty sleeping can be a side effect of the medication, but the client should discuss any concerns with the healthcare provider before stopping the medication.

I’ll call my doctor immediately with any early signs of congestion: While it is important to report any signs of infection or congestion, it is not directly related to risperidone use. Respiratory symptoms are not common early side effects of this medication, and while reporting them is always wise, this specific instruction is not the most directly relevant to risperidone's known side effects.

Ensure the client has information regarding their diagnosis: While providing information about the client’s diagnosis is important for future treatment and understanding, it is not the most immediate priority during a psychotic episode. The client’s comprehension may be impaired, and their immediate safety and stabilization should take precedence over education.

Call the family and discuss a family therapy session: Family support is valuable in the long-term management of psychosis, but contacting the family is not the top priority during a severe psychotic episode. The immediate concern is ensuring the client's safety and addressing acute symptoms before involving family members for therapy.

Call the doctor to request loxapine: While medication may be necessary to manage the symptoms of a psychotic episode, ensuring the client’s safety is the first priority. The nurse should assess the situation and provide immediate care to prevent injury, while simultaneously communicating with the doctor regarding the medication and treatment plan.

Olanzapine: Olanzapine is an atypical antipsychotic that is used to treat conditions such as schizophrenia and bipolar disorder, but it would not be used to treat severe muscle spasms caused by chlorpromazine. This medication is not appropriate for managing extrapyramidal side effects (EPS) like the muscle spasms described in the question.

Flumazenil: Flumazenil is a benzodiazepine antagonist used for the reversal of benzodiazepine overdoses or excessive sedation, but it is not indicated for managing the side effects of antipsychotic medications like chlorpromazine. The symptoms described in the question are more related to extrapyramidal symptoms rather than benzodiazepine toxicity.

Fluphenazine: Fluphenazine is another antipsychotic medication within the same class as chlorpromazine (typical antipsychotics). Administering fluphenazine would not treat the muscle spasms or other side effects caused by chlorpromazine. In fact, it may worsen the symptoms. The focus should be on managing the side effects rather than increasing the antipsychotic dosage.

Grandeur: A delusion of grandeur involves the belief that one has exceptional abilities, power, or importance, such as thinking they are a famous person or have special powers. While the client believes they have a powerful ability (telepathy), the belief is more about influencing events than an inflated sense of personal superiority or power.

Persecution: Delusions of persecution involve the belief that one is being targeted, harassed, or harmed by others. The client's statement does not reflect fear of being harmed or targeted by others but rather reflects a belief in using their mind to manipulate an outcome, so this is not an example of a persecutory delusion.

Thought withdrawal: Thought withdrawal is the delusion that one's thoughts are being taken away or removed by an external force. The client's statement does not suggest that their thoughts are being stolen, but rather that they are using their thoughts to control or influence another person, which rules out this delusion.

Delirium and anxiety: While delirium and anxiety can be seen in some patients taking medications, they are not the most common side effects of typical antipsychotics. Typical antipsychotics, such as chlorpromazine or haloperidol, are more likely to cause anticholinergic effects or extrapyramidal symptoms, not delirium or anxiety, so this is less relevant in this case.

Dysthythmia and headache: While dysthythmia (irregular heart rhythms) and headache may occur as side effects of some medications, they are not the most common or expected side effects of typical antipsychotics. The nurse would be more concerned with anticholinergic effects or extrapyramidal symptoms in this context.

Diarrhea and flatus: Diarrhea and excessive gas (flatus) are not typical side effects of antipsychotics. In fact, the opposite is more common due to the anticholinergic effects of these medications, which can cause constipation and difficulty with bowel movements, not diarrhea.

The client has gained 1.4 kg (3 lb) in the past month: Weight gain can be a side effect of clozapine, but a 3-pound gain over the course of a month is not an immediate concern. The nurse should continue to monitor the client's weight, but this alone is not a reason to withhold clozapine.

The client reports being constipated for 2 days: Constipation is a common side effect of clozapine due to its anticholinergic properties. While the nurse should address constipation and encourage interventions like increased fluid intake or stool softeners, it is not a reason to withhold clozapine unless the constipation becomes severe or leads to other complications like bowel obstruction.

The client reports feeling dizzy when getting out of bed: Dizziness, particularly upon standing (orthostatic hypotension), is a common side effect of clozapine. The nurse should assess the severity of the dizziness and encourage the client to rise slowly from a sitting or lying position, but dizziness alone is not a reason to withhold the medication. However, if the dizziness is severe or persists, the nurse should notify the healthcare provider.

Why do you think nobody loves you?: This response may come across as dismissive or as questioning the client's feelings. It could potentially make the client feel defensive or misunderstood. Instead of questioning the client, it is more important to acknowledge their emotional state and offer support.

I am sure your parents love you: While the nurse may be trying to reassure the client, this response can minimize the client’s feelings. It also assumes that the issue is related to the parents, which may not be the case. It’s important to allow the client to express their feelings without prematurely offering reassurance.

"Don't worry, things will get better.": While this response is meant to be comforting, it can be seen as invalidating the client’s current emotional experience. It dismisses the client's distress by suggesting that things will get better without addressing the emotions they are expressing in the moment.