A family member says to the nurse, "I think my sister needs more medication because she says she cannot sit still and is moving her legs back and forth." The client's risperidone (Risperdal) was recently increased to 10 mg daily

Question

What is the correct nursing response? 1. "I will check with your sister because what you are describing sounds like a side effect called akathisia."
2. "I will check to see what your sister has been prescribed because some clients get anxious when their medications are increased."
3. "I will see if your sister has been prescribed a medication to counteract the dystonic reaction that she is having."
4. "I will call the doctor and report that your sister is developing a tolerance to risperidone and the dose is not effective."

Answer 1

1
Rationale: Akathisia is the inability to sit still for more than a few minutes or the feeling of not being able to sit still. It is a side effect of antipsychotic medication that can be very distressing to the client. The nurse should assess the patient to determine if she has akathisia. It would not be typical for a client to get anxious just because the medications were increased. A dystonia would be an abnormal tonic muscle contraction. Risperidone is not addictive and clients do not develop tolerance to it.