What to Do When a Patient Experiences Torticollis After Fluphenazine

A client has received her first dose of fluphenazine (Prolixin) and experiences torticollis. What is an appropriate measure for the nurse to implement?

• A. Have respiratory support equipment available
• B. Immediately place her in the seclusion room
• C. Assess the client for anxiety and agitation
• D. Administer PRN dose of IM antipsychotic medication

Answer: (A)

In the scenario provided, the client is experiencing torticollis, which is a form of acute dystonia characterized by involuntary muscle contractions that cause the head to twist or turn to one side. This is a potential side effect of antipsychotic medications like fluphenazine, indicating that the medication may have induced an acute dystonic reaction. Having respiratory support equipment available is an appropriate measure because acute dystonia can lead to complications such as airway obstruction or respiratory distress if the muscle contractions affect the neck and throat. Preparedness to provide respiratory support is crucial in case the client's condition worsens and they experience difficulty breathing. The other options are less suitable in this immediate context. Placing the client in a seclusion room might not address the acute physical symptoms they are experiencing and could potentially escalate feelings of anxiety or agitation. Assessing the client for anxiety and agitation might provide useful information, but it does not address the urgent need for physical intervention related to the torticollis. Administering a PRN dose of IM antipsychotic medication could potentially exacerbate the situation or lead to further side effects, and would not be the best first-line response to an acute dystonic reaction. By securing respiratory support equipment, the nurse

Understanding how to manage reactions like torticollis after fluphenazine is crucial for nursing students preparing for the HESI Registered Nurse EXIT Exam. You know that feeling of anxiety when faced with a patient's sudden condition? Remember, a calm and prepared nurse is essential for patient outcomes.

So, let’s talk torticollis. This acute dystonia, often a side effect of antipsychotic medications like fluphenazine (Prolixin), can be alarming. Imagine your client twisting their head involuntarily—the urgency of the situation rises. What should you do? First things first, remember to have respiratory support equipment ready. Why? Because these muscle contractions can lead to complications, including airway obstruction or respiratory distress. Yes, your role as a nurse is to be proactive in securing their safety.

Let’s break down the other options you might be tempted to consider. Is it a good idea to immediately seclude the client? Not really. Sure, seclusion can help manage challenging behaviors, but during an acute physical reaction like torticollis, addressing the physical symptoms takes precedence. Just think: would confining a patient in distress ease their current symptoms or add to their anxiety?

Next, there’s the option to assess for anxiety and agitation. While it’s always beneficial to evaluate a patient’s emotional and psychological state, this doesn’t immediately treat the urgency of an acute physical response. You want to ensure that your actions align with immediate medical needs.

Now, what about administering a PRN IM antipsychotic? While that sounds like it could help, it may worsen the situation or lead to further side effects, which isn't what anyone wants in an acute dystonic reaction scenario.

Instead, preparing for respiratory support is your safest bet. You’re not just reacting; you’re ensuring a safety net should things escalate. This proactive approach underscores the nurse's role in stabilizing the patient's condition before all else.

Here’s the thing—nursing school comes with a heap of knowledge, but being able to think critically and calmly when situations arise? That’s where the real test lies. So, whether you’re preparing for your upcoming nursing exam or stepping into a clinical role, keep these interventions in your toolkit. Knowing the right actions to take not only calms your patients but also brings you peace of mind.

As you get ready for your exam, remember that every clinical situation will require you to be on your toes, thinking and acting swiftly. Preparing for potential reactions and knowing how to respond can make all the difference in effective patient care. Good luck, and trust that you’ve got the tools to succeed!