HESI Registered Nurse EXIT Practice Exam

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

1. Have respiratory support equipment available

2. Immediately place her in the seclusion room

3. Assess the client for anxiety and agitation

4. Administer PRN dose of IM antipsychotic medication

The correct answer is: Have respiratory support equipment available

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