6. A client receiving haloperidol (Haldol) complains of a stiff jaw anddifficulty swallowing. The nurse's first action is to:A. reassure the client and administer as needed lorazepam (Ativan)I.M.
B. administer as needed dose of benztropine (Cogentin) I.M. asordered.
C. administer as needed dose of benztropine (Cogentin) by mouth asordered.D. administer as needed dose of haloperidol (Haldol) by mouth.Rationale: The client is most likely suffering from muscle rigidity dueto haloperidol. I.M. benztropine should be administered to preventasphyxia or aspiration. Lorazepam treats anxiety, not extrapyramidaleffects. Another dose of haloperidol would increase the severity of thereaction.7. A client with a diagnosis of paranoid schizophrenia comments to thenurse, "How do I know what is really in those pills?" Which of thefollowing is the best response?A. Say, "You know it's your medicine."
B. Allow him to open the individual wrappers of the medication.
C. Say, "Don't worry about what is in the pills. It's what is ordered."D. Ignore the comment because it's probably a joke.Rationale: Option B is correct because allowing a paranoid client toopen his medication can help reduce suspiciousness. Option A isincorrect because the client doesn't know that it's his medication andhe's obviously suspicious. Telling the client not to worry or ignoring thecomment isn't supportive and doesn't offer reassurance.8. The nurse is caring for a client with schizophrenia who experiencesauditory hallucinations. The client appears to be listening to someonewho isn't visible. He gestures, shouts angrily, and stops shouting inmid-sentence. Which nursing intervention is the most appropriate?A. Approach the client and touch him to get his attention.B. Encourage the client to go to his room where he'll experience fewerdistractions.
C. Acknowledge that the client is hearing voices but make itclear that the nurse doesn't hear these voices.
D. Ask the client to describe what the voices are saying.Rationale: By acknowledging that the client hears voices, the nurseconveys acceptance of the client. By letting the client know that thenurse doesn't hear the voices, the nurse avoids reinforcing thehallucination. The nurse shouldn't touch the client with schizophrenia