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. Allowing the client to continue at his own pace may not effectively address the issue of circumstantiality and could lead to prolonged, tangential conversations.
B) Correct. Redirecting the conversation can help the client refocus and stay on topic, which can be particularly helpful for someone experiencing circumstantiality.
C) Incorrect. Stopping the client and telling him how his conversation sounds to others may be perceived as confrontational and could potentially be distressing for the client.
D) Incorrect. Reflecting is a useful communication technique, but it may not be the most effective intervention for addressing circumstantiality in this scenario.
Correct Answer is B
Explanation
A) Incorrect. While monitoring sodium levels can be important for clients on certain
medications, it is not a primary concern with lamotrigine. The main concern is the potential for a serious rash.
B) Correct. Lamotrigine is associated with a risk of a severe skin reaction called Stevens Johnson syndrome. If a client experiences any rash while taking lamotrigine, it is crucial to notify a
healthcare provider immediately.
C) Incorrect. While monitoring weight and potential changes in appetite are important aspects of overall health, it is not a specific teaching point for lamotrigine.
D) Incorrect. While it is important for individuals of childbearing age to discuss pregnancy plans and contraceptive methods with their healthcare provider, it is not the primary teaching point specific to lamotrigine.
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