Psychotic Disorders no. 4017

Psychotic Disorders no. 4017

QUESTION: A client with schizophrenia is receiving antipsychotic medication. Which nursing diagnosis may be appropriate for this client?

✓O a.) <i>Ineffective protection related to blood dyscrasias</i>
✘O b.) <i>Reflex urinary incontinence related to adverse effects of antipsychotic medication</i>
✘O c.) <i>Risk for injury related to a severely decreased level of consciousness</i>
✘O d.) <i>Risk for injury related to electrolyte disturbances</i>

RATIONALE

RATIONALE: Antipsychotic medications may cause neutropenia and granulocytopenia, life-threatening blood dyscrasias that warrant a nursing diagnosis of <i>Ineffective protection related to blood dyscrasias.</i> These medications also have anticholinergic effects, such as urine retention, dry mouth, and constipation. Reflex urinary incontinence isn't an adverse effect of these medications. Although antipsychotic medications may cause sedation, they don't severely decrease the level of consciousness, eliminating option 3. These drugs don't cause electrolyte disturbances, eliminating option 4.
NURSING PROCESS STEP: Analysis
CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge