A nurse on an inpatient unit is caring for a client who has schizophrenia and recently started taking risperidone. Which of the following actions should the nurse take?
Explanation & Rationale
A. Implement fall precautions for the client. This is correct because risperidone can cause orthostatic hypotension, which can increase the risk of falls and injuries. The nurse should advise the client to change positions slowly, avoid alcohol and dehydration, and use assistive devices as needed. B. Monitor the client's thyroid function. This is incorrect because risperidone does not affect thyroid function. The nurse should monitor the client's thyroid function if they are taking lithium, which can cause hypothyroidism. C. Place the client on a fluid restriction. This is incorrect because risperidone does not cause fluid retention or overload. The nurse should encourage adequate fluid intake and monitor the client's fluid balance. D. Discontinue the medication if hallucinations occur. This is incorrect because hallucinations are a symptom of schizophrenia, not a side effect of risperidone. The nurse should not discontinue the medication abruptly, as this can cause withdrawal symptoms and relapse of psychosis. The nurse should assess the client's response to the medication, report any adverse effects, and adjust the dosage as prescribed.