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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. "As depression lifts, physical energy becomes available to carry out suicide." This statement highlights a critical consideration in the care of severely depressed clients. When a client's depression starts to improve due to antidepressant therapy, there may be a period where they have increased energy but have not yet gained full relief from their depressive thoughts. This can potentially increase the risk of carrying out suicidal thoughts or plans.

B. "Suicide may be precipitated by a variety of internal and external events." While this statement is true, it does not specifically address the importance of monitoring a client during antidepressant therapy.

C. "Suicidal clients have difficulty using social supports." This statement acknowledges a potential challenge for clients who are experiencing suicidal thoughts, but it does not directly relate to the need for close monitoring during antidepressant therapy.

D. "Suicide is an impulsive act that has no warning." This statement is not entirely accurate. While some suicides can be impulsive, many individuals give warning signs or exhibit changes in behavior before attempting suicide.

Correct Answer is ["10"]

Explanation

Dose (mL) = Desired dose (mg) / Available dose (mg/mL) Plugging in the values from the question, we get:
Dose (mL) = 80 mg / (40 mg / 5 mL) Simplifying the fraction, we get:
Dose (mL) = 80 mg / 8 mg/mL Dividing both sides by 8, we get:
Dose (mL) = 10 mL
Therefore, the nurse should administer 10 mL of fluoxetine per dose.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement provides the best rationale for why a nurse should closely monitor a severely depressed client during antidepressant therapy?

Correct Answer is A

Explanation

A nurse is preparing to administer fluoxetine 80 mg PO daily. Available is fluoxetine 40 mg/5mL. How many mL should the nurse administer per dose? (Write the number only, do not include the label. Record the answer to the nearest whole number. Do not use a trailing zero)

Correct Answer is ["10"]

Explanation

While caring for a depressed client, a nurse would evaluate the need for suicide precautions under which circumstance?

A newly admitted client has a diagnosis of schizoaffective disorder. Based on this diagnosis, the nurse would expect to find which of the following symptoms?

A client is admitted to the emergency department after using ecstasy. The nurse identifies this drug as belonging to what class?

The nurse receives report on a male client diagnosed with schizoaffective disorder and is informed that the client's verbal communication includes "circumstantiality." What intervention is most therapeutic when caring for this client?

A client diagnosed with major depressive disorder with psychotic features hears voices commanding self harm. The client refuses to commit to developing a plan for safety. What should be the nurse's priority intervention at this time?

What client population is at risk of developing tardive dyskinesia?

The nurse is caring for a client who has become increasingly agitated. He is pacing in the hallway and shouting at other clients. What is the priority action of the nurse?

An older adult in the middle and late stages of Alzheimer's forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the client's family?