Psychotic Disorders no. 4040
QUESTION: Yesterday, a client with schizophrenia began treatment with haloperidol (Haldol). Today, the nurse notices that the client is holding his head to one side and complaining of neck and jaw spasms. What should the nurse do?
✘O a.) Assume that the client is posturing.
✘O b.) Tell the client to lie down and relax.
✓O c.) Evaluate the client for adverse reactions to haloperidol.
✘O d.) Put the client on the list for the physician to see tomorrow.
RATIONALERATIONALE: An antipsychotic agent such as haloperidol can cause muscle spasms in the neck, face, tongue, back, and sometimes legs as well as torticollis (twisted neck position). The nurse should be aware of these adverse reactions and assess for related reactions promptly. Although posturing may occur in clients with schizophrenia, it isn't the same as neck and jaw spasms. Having the client relax can reduce tension-induced muscle stiffness but not drug-induced muscle spasms. When a client develops a new sign or symptom, the nurse should consider an adverse drug reaction as the possible cause and obtain treatment immediately, rather than have the client wait.NURSING PROCESS STEP: EvaluationCLIENT NEEDS CATEGORY: Physiological integrityCLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapiesCOGNITIVE LEVEL: Application
