A client receives risperidone (Risperdal). The nurse observes that the client is experiencing severe muscle spasms of his back and neck. Which nursing action is a priority for this client?
1. Administer an additional dose of risperidone (Risperdal).
2. Withhold risperidone (Risperdal) until the symptoms subside.
3. Encourage the client to take a warm shower to relax the muscles.
4. Administer benztropine (Cogentin) IM.
Correct Answer: D
Rationale 1: Administering an additional dose of risperidone (Risperdal) is incorrect because this would make the muscle spasms worse.
Rationale 2: Withholding risperidone (Risperdal) until the symptoms subside is incorrect because the symptoms of acute dystonia will not subside unless an anticholinergic drug such as benztropine is administered.
Rationale 3: Encouraging the client to take a warm shower to relax the muscles is incorrect because a warm shower will be ineffective.
Rationale 4: Severe muscle spasms are a manifestation of acute dystonia. This is an extrapyramidal side effect associated with antipsychotic medications. Drug therapy with an anticholinergic drug such as benztropine (Cogentin) is recommended. This drug is given parenterally. The symptoms of acute dystonia will not subside unless an anticholinergic drug such as benztropine is administered.
Global Rationale: Severe muscle spasms are a manifestation of acute dystonia. This is an extrapyramidal side effect associated with antipsychotic medications. Drug therapy with an anticholinergic drug such as benztropine (Cogentin) is recommended. This drug is given parenterally. The symptoms of acute dystonia will not subside unless an anticholinergic drug such as benztropine is administered. Administering an additional dose of risperidone (Risperdal) is incorrect because this would make the muscle spasms worse. Withholding risperidone (Risperdal) until the symptoms subside is incorrect because the symptoms of acute dystonia will not subside unless an anticholinergic drug such as benztropine is administered. Encouraging the client to take a warm shower to relax the muscles is incorrect because a warm shower will be ineffective.
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