Answer to Question 1
Correct Answer: D
Rationale 1: Administering an additional dose of risperidone (Risperdal) is incorrect because this would make the muscle spasms worse.
Rationale 2: Withholding risperidone (Risperdal) until the symptoms subside is incorrect because the symptoms of acute dystonia will not subside unless an anticholinergic drug such as benztropine is administered.
Rationale 3: Encouraging the client to take a warm shower to relax the muscles is incorrect because a warm shower will be ineffective.
Rationale 4: Severe muscle spasms are a manifestation of acute dystonia. This is an extrapyramidal side effect associated with antipsychotic medications. Drug therapy with an anticholinergic drug such as benztropine (Cogentin) is recommended. This drug is given parenterally. The symptoms of acute dystonia will not subside unless an anticholinergic drug such as benztropine is administered.
Global Rationale: Severe muscle spasms are a manifestation of acute dystonia. This is an extrapyramidal side effect associated with antipsychotic medications. Drug therapy with an anticholinergic drug such as benztropine (Cogentin) is recommended. This drug is given parenterally. The symptoms of acute dystonia will not subside unless an anticholinergic drug such as benztropine is administered. Administering an additional dose of risperidone (Risperdal) is incorrect because this would make the muscle spasms worse. Withholding risperidone (Risperdal) until the symptoms subside is incorrect because the symptoms of acute dystonia will not subside unless an anticholinergic drug such as benztropine is administered. Encouraging the client to take a warm shower to relax the muscles is incorrect because a warm shower will be ineffective.
Answer to Question 2
Correct Answer: 2
Rationale 1: Increased appetite is a common side effect of clozapine and does not require immediate reporting.
Rationale 2: A sore throat is a symptom of depressed immune function that is associated with agranulocytosis. This must be reported immediately.
Rationale 3: Drowsiness is a common side effect of clozapine and does not require immediate reporting.
Rationale 4: Constipation is a common side effect of clozapine and does not require immediate reporting.
Global Rationale: A sore throat is a symptom of depressed immune function that is associated with agranulocytosis. This must be reported immediately. Increased appetite is a common side effect of clozapine, and does not require immediate reporting. Drowsiness is a common side effect of clozapine, and does not require immediate reporting. Constipation is a common side effect of clozapine, and does not require immediate reporting.
The patient and his family meet with the nurse to discuss progress on the patient care plan.
The nurse assesses the patient's ability to use the walker correctly
A nurse prepares a client for anesthesia and surgery.
Example of simplified note for one-time client.