The client receives prochlorperazine (Compazine) for nausea and vomiting. The nurse notices that the client is exhibiting a stiff neck, turned to the side. What is the best action by the nurse?
1. Administer the client's as needed analgesic immediately.
2. Contact the physician immediately.
3. Hold the next dose and observe the client.
4. Ask the client if she has ever experienced this before.
Correct Answer: 2
Rationale 1: Giving an analgesic is not the priority intervention.
Rationale 2: Prochlorperazine (Compazine) is a phenothiazine drug; the client is experiencing an extrapyramidal side effect known as dystonia. The nurse should immediately alert the physician and prepare to administer an antidote.
Rationale 3: The client needs an antidote; holding the next dose will not relieve the symptoms.
Rationale 4: Assessment is good, but the client needs an antidote.
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