Nokea
Before administering a prescribed antipsychotic drug to a client, the nurse observes the client for any behavior patterns that appear to be deviations from normal. Which of the following would the nurse identify as a deviation? Select all that apply.
- A. Poor eye contact
- B. Monotone speech pattern
- C. Inappropriate laughter
- D. Failure to answer questions completely
- E. Inappropriate crying
Correct Answer: A,B,C,D,E
Rationale: Examples of deviation from normal include poor eye contact, failure to answer questions completely, inappropriate answers to questions, a monotone speech pattern, and inappropriate laughter, sadness, or crying.
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Which of the following are reasons a nurse may need to contact the client's physician to administer an antipsychotic drug intramuscularly instead of orally? Select all that apply.
- A. Client is combative.
- B. Client refuses the medication.
- C. Client won't allow the nurse to inspect the oral cavity.
- D. Client has difficulty swallowing.
- E. Client is elderly.
Correct Answer: A,B,C
Rationale: A nurse may need to contact the client's physician to administer an antipsychotic drug intramuscularly instead of orally because the client is combative, refuses the medication, or refuses to allow the nurse to inspect the oral cavity. Clients who have difficulty swallowing may be given an oral liquid in lieu of an IM injection.
Antipsychotic therapy with a conventional antipsychotic has been started for a client with schizophrenia. Assessment reveals that the client is experiencing drowsiness that is affecting his ability to function. The nurse notes that the client needs assistance with his activities of daily living and ambulating. Which nursing diagnosis would the nurse most likely identify?
- A. Risk for Infection
- B. Risk for Unstable Blood Glucose Level
- C. Risk for Injury
- D. Impaired Physical Mobility
Correct Answer: C
Rationale: Antipsychotic drugs may cause extreme drowsiness and sedation, especially during the first or second weeks of therapy. This reaction may impair mental or physical abilities. The patient may need assistance with activities of daily living due to the experience of extreme sedation. This includes cueing or help with eating, dressing, and ambulating. Therefore, Risk for Injury would be most appropriate. Risk for Infection would be appropriate if the client was receiving clozapine. Risk for Unstable Blood Glucose Level would be appropriate if the client was receiving an atypical antipsychotic due to the increased risk for weight gain and subsequent development of diabetes. Impaired Physical Mobility would be appropriate if the client was experiencing EPS or TD.
A client is prescribed clozapine. The nurse instructs the client on the need for weekly laboratory testing for which of the following?
- A. Serum lithium
- B. WBC count
- C. Blood glucose
- D. pH level
Correct Answer: B
Rationale: Use of the drug clozapine has been associated with severe agranulocytosis (i.e., decreased white blood cells), so weekly WBC count tests are scheduled. Serum lithium tests are taken for clients who have been administered lithium, not clozapine. There is no need to check blood glucose or pH level.
After administering an antipsychotic to a client, the nurse would immediately report which of the following?
- A. Orthostatic hypotension
- B. Dry mouth
- C. Rigidity
- D. Drowsiness
Correct Answer: C
Rationale: The nurse should immediately report to the primary health care provider if the client displays signs of rigidity. Dry mouth, episodes of orthostatic hypotension, and drowsiness are reactions that are considered normal during drug therapy and need not be reported unless severe.
A nurse should be able to differentiate between the typical and atypical antipsychotics. Which of the following would the nurse identify as an atypical antipsychotic? Select all that apply.
- A. Lithium (Eskalith)
- B. Aripiprazole (Abilify)
- C. Chlorpromazine (Thorazine)
- D. Prochlorperazine (Compazine)
- E. Clozapine (Clozaril)
Correct Answer: B,E
Rationale: Aripiprazole (Abilify) and clozapine (Clozaril) are classified as atypical antipsychotics.