A client receiving risperidone reports severe muscle stiffness at 1030. By 1200, the client has difficulty swallowing food and is drooling. The client is diaphoretic. By 1600, vital signs are as follows Temperature 102.8 F pulse 110 beats/minute, respirations 26 breaths/minute, and blood pressure 150/90 mmHg.
What is the nurse's best analysis and action?
Institute reverse isolation
Withhold the next dose of medication
Begin high protein, high cholesterol diet
Notify health care provider stat
The Correct Answer is D
A) Incorrect. Reverse isolation is not indicated in this situation. The client's symptoms are likely due to a side effect of the medication, not an infectious process.
B) Incorrect. While it may be necessary to withhold the next dose of medication, the client's symptoms require more immediate attention.
C) Incorrect. The client's symptoms are indicative of a serious adverse reaction, and dietary changes would not address the issue.
D) Correct. The client's symptoms, including severe muscle stiffness, difficulty swallowing, drooling, diaphoresis, and elevated vital signs, are indicative of neuroleptic malignant syndrome (NMS), a potentially life-threatening side effect of antipsychotic medications like risperidone.
The nurse should notify the healthcare provider immediately for further guidance and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect. While understanding if the client is experiencing a relapse is important, knowing the timing of the last drink is crucial for assessing the level of intoxication.
B) Correct. Knowing the time of the last drink helps the nurse gauge the current level of alcohol in the client's system, which is crucial in assessing and managing alcohol intoxication.
C) Incorrect. While understanding the duration of the client's problem with alcohol is important, it is not the most immediate concern when the client is showing symptoms of intoxication.
D) Incorrect. Asking about liver problems is relevant but not the first priority when the client is exhibiting signs of alcohol intoxication.
Correct Answer is B
Explanation
A) Incorrect. While maintaining proper nutrition is important, this statement is not directly related to the use of risperidone.
B) Correct. Risperidone, an atypical antipsychotic, can be associated with metabolic side effects, including hypertension. Therefore, monitoring blood pressure is important.
C) Incorrect. While regular monitoring of blood parameters may be necessary for some medications, it is not a specific requirement for risperidone.
D) Incorrect. While weight changes can occur with risperidone, there is no specific indication to increase caloric intake in this context.
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