A client is prescribed fluphenazine (Prolixin) and is experiencing muscle spasms of the neck. The client is grimacing and having difficulty speaking. Which action should the nurse take?

Question

1. Call the health care provider and prepare to give chlorpromazine (Thorazine) IM.
2. Distract the client to confirm the client is not faking a muscle spasm.
3. Call the health care provider and prepare to give diphenhydramine (Benadryl).
4. Engage the client in open-ended conversation to find out why the client is having difficulty speaking.

Answer 1

Correct Answer: 3
Rationale 1: Chlorpromazine (Thorazine) is not used to treat dystonia.
Rationale 2: Muscle spasms are difficult to fake.
Rationale 3: Signs of acute dystonia associated with fluphenazine include severe muscle spasms of the back, neck, tongue, and face. It can be so severe as to cause laryngospasm. When treated with diphenhydramine (Benadryl), it can be reversed within minutes.
Rationale 4: The client is having difficulty speaking. This would not be an appropriate action.
Global Rationale: Signs of acute dystonia associated with fluphenazine include severe muscle spasms of the back, neck, tongue, and face. It can be so severe as to cause laryngospasm. When treated with diphenhydramine (Benadryl), it can be reversed within minutes. Chlorpromazine (Thorazine) is not used to treat dystonia. Muscle spasms are difficult to fake. The client is having difficulty speaking; therefore, engaging the client in a conversation would not be an appropriate action.