A client has been managed on chlorpromazine (Thorazine) for some time for schizophrenia. The nurse assesses the client prior to administering the medication and notes the client's lip smacking, blinking, and tongue protrusion
The initial action by the nurse would be to:
1. give the medication.
2. call a code.
3. hold the medication and notify the physician.
4. notify the charge nurse.
Answer: 3
1. The client is exhibiting signs of tardive dyskinesia, which is a dangerous and permanent side effect of antipsychotics. The nurse should not give the medication.
2. Calling a code is not necessary unless vital signs are compromised.
3. The nurse should withhold the medication and notify the physician immediately.
4. The charge nurse may be notified after the physician has been notified.
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