The nurse is managing the care of a group of patients with schizophrenia. The patients are receiving conventional antipsychotic medications. When assessing for anticholinergic side effects, which would the nurse immediately report to the physician?
1. Acute dystonia
2. Complaint of a severe headache
3. Hypertension
4. Urinary retention
4
Rationale 1: Acute dystonia must be reported immediately to the physician, but this is not an anticholinergic side effect.
Rationale 2: Headaches are not anticholinergic side effects.
Rationale 3: Hypotension, not hypertension, is a cardiac side effect, not an anticholinergic side effect.
Rationale 4: Urinary retention is an anticholinergic side effect of conventional antipsychotics. This must be reported immediately to the physician.
Global Rationale: Urinary retention is an anticholinergic side effect of conventional antipsychotics. This must be reported immediately to the physician. Hypotension, not hypertension, is a cardiac side effect, not an anticholinergic side effect. Headaches are not anticholinergic side effects. Acute dystonia must be reported immediately to the physician, but this is not an anticholinergic side effect.
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