Difficulty: Medium
Average Score: 86%
Simulated
A male client with a history of substance use disorder visits the clinic reporting anxiety and concern about a possible relapse. Which action should the nurse take first?
Correct answer
D
Rationale
The client's laterally contracted posture is a classic presentation of acute dystonia, an extrapyramidal side effect (EPS) of antipsychotic medications like risperidone. His report of his body being "contorted into a monster" is his psychotic interpretation of this painful, involuntary muscle spasm. The appropriate and immediate treatment is to administer an anticholinergic agent like benztropine to relieve the muscle contraction. Distracting the client (A) or applying a hot pack (C) does not address the underlying neurochemical cause. Administering another antipsychotic (B) would be contraindicated as it could worsen the EPS.