Nokea
When assessing a client receiving antipsychotic drugs, the nurse would suspect that the client is experiencing extrapyramidal syndrome (EPS) based on assessment of which of the following? Select all that apply.
- A. Fine tremor
- B. Hypotension
- C. Akathisia
- D. Anhedonia
- E. Dystonia
Correct Answer: A,C,E
Rationale: The signs of EPS include fine tremors, muscle rigidity, mask-like appearance of the face, slowness of movement, slurred speech, unsteady gait, akathisia, and dystonia. Anhedonia is a manifestation of schizophrenia.
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A nurse caring for a client receiving clozapine (Clozaril) needs to be mindful of the symptoms that indicate bone marrow suppression. Assessment of which of the following would lead the nurse to suspect that the client is experiencing bone marrow suppression? Select all that apply.
- A. Hypertension
- B. Sore throat
- C. Fever
- D. Chills
- E. Weakness
Correct Answer: B,C,D,E
Rationale: Symptoms that indicate bone marrow suppression include lethargy, weakness, fever, sore throat, malaise, mucous membrane ulceration, and 'flu-like' complaints.
A client with schizophrenia is prescribed antipsychotic therapy. When developing the plan of care for the client, the nurse integrates understanding that the client is at risk for extrapyramidal syndrome. The nurse would expect to assess the client for this adverse reaction at which time?
- A. Once a week
- B. At the initiation of therapy
- C. When the dose is reduced
- D. Every 3 months
- E. When the dose is increased
Correct Answer: B,C,E
Rationale: The nurse should assess for EPS during initial therapy and whenever the dosage is increased or decreased.
After teaching a group of nursing students about antipsychotic drugs, the instructor determines that the teaching was successful when the students identify aripiprazole (Abilify) as exerting its effect on which of the following in the brain? Select all that apply.
- A. Serotonin
- B. Dopamine
- C. Norepinephrine
- D. Muscarinic
- E. Nicotinic
Correct Answer: A,B
Rationale: Atypical antipsychotic drugs like aripiprazole (Abilify) are thought to act on serotonin and dopamine receptors in the brain. The conventional, or first-generation, antipsychotics (FGAs) work to diminish the positive symptoms by blocking dopamine transmission.
A nurse observes rhythmic, involuntary facial movements in a client who has been receiving antipsychotic drugs. The client also makes chewing movements and, at times, his tongue protrudes. The nurse interprets these findings as which of the following?
- A. Stevens-Johnson syndrome
- B. Neuropeptic malignant syndrome
- C. Tardive dyskinesia
- D. Extrapyramidal syndrome
Correct Answer: C
Rationale: Tardive dyskinesia is characterized by rhythmic, involuntary movements of the tongue, face, mouth, or jaw and sometimes the extremities. The tongue may protrude, and there may be chewing movements, puckering of the mouth, and facial grimacing. Extrapyramidal syndrome (EPS), neuroleptic malignant syndrome (NMS), and Stevens-Johnson syndrome do not cause rhythmic, involuntary facial movements.
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.