During a psychiatric emergency, IM ziprasidone (Geodon) is administered to an assaultive patient. During the next 2 hours, it is of primary importance that the nurse assess for:

Correct Answer: C

Rationale: The correct answer is C: Orthostatic hypotension. When administering IM ziprasidone to an assaultive patient, the nurse should assess for orthostatic hypotension as it is a common side effect that can lead to dizziness and falls. It is crucial to monitor the patient's blood pressure and pulse when changing positions to prevent complications. Tardive dyskinesia (choice A) is a long-term side effect of antipsychotic medications, usually seen after prolonged use. Anticholinergic effects (choice B) are more commonly associated with medications like antihistamines and tricyclic antidepressants. Pseudoparkinsonism (choice D) refers to symptoms resembling Parkinson's disease and is a side effect of certain antipsychotic medications, but it is not the primary concern immediately after administering IM ziprasidone.

Correct Answer: B

Rationale: The correct answer is B: MRI. An MRI is the best test to rule out a brain tumor due to its ability to provide detailed images of the brain structure, helping to identify any abnormalities like tumors. PET scans (A) are used to detect brain activity, not for tumor identification. EEG (C) is used to evaluate brain electrical activity, not for tumor detection. Cerebral arteriogram (D) is used to assess blood vessels in the brain, not for tumor detection.

Correct Answer: A

Rationale: The correct answer is A because lithium is excreted in breast milk, posing a risk of toxicity to the infant. This statement demonstrates understanding of the direct impact of lithium on breast milk composition. Choice B is incorrect as lithium does not typically affect the taste of breast milk or cause gas in infants. Choice C is incorrect as lithium may not necessarily impact lactation directly. Choice D is incorrect as mood fluctuations from lithium do not directly affect breast milk production.

Correct Answer: C

Rationale: The correct answer is C because a client who has had a total knee replacement may have metal implants, which can interfere with the MRI imaging and pose a safety risk. The nurse should decline to make test arrangements without further discussion with the physician to ensure the safety and appropriateness of the test. Choice A (breastfeeding) is not a contraindication for an MRI, as it is safe for breastfeeding mothers. Choice B (allergic to iodine) is also not a reason to decline an MRI, as contrast agents without iodine can be used. Choice D (neuroleptic medication) may affect the MRI results, but it is not a reason to decline the test outright without further discussion with the physician.

Correct Answer: B

Rationale: The correct answer is B. The nurse should explain that it may take up to 4 weeks to notice any therapeutic effects of the new medication for depression. This is because antidepressants typically require time to build up in the patient's system and start producing the desired effects. By advising to wait a little longer, the nurse is providing accurate information and managing the wife's expectations appropriately. Incorrect Choices: A: This answer prematurely suggests changing the medication without allowing sufficient time for the current medication to take effect. C: Increasing the dosage without waiting for the full therapeutic effect to manifest can lead to unnecessary side effects and risks. D: This answer is pessimistic and does not offer constructive guidance or hope for improvement, which is not appropriate in this situation.