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 D
Explanation
A. This option is too vague and doesn't provide specific guidance about the detoxification process for alprazolam.
B. Frequency of usage is one factor, but it's not the only consideration in the detoxification process.
C. A planned reduction is necessary to safely taper off alprazolam and minimize withdrawal symptoms.
D. This option provides the best guidance, emphasizing the importance of a gradual and controlled tapering process for alprazolam.
Correct Answer is C
Explanation
A) Incorrect. While discussing various topics is important, providing continuity of care is more crucial in creating a therapeutic environment for clients with paranoia and schizophrenia.
B) Incorrect. Focusing on client strengths rather than weaknesses is generally a more effective approach in mental health care.
C) Correct. Providing continuity of care by assigning the same staff helps build trust and a sense of security for clients, especially those with paranoia and schizophrenia.
D) Incorrect. While it's important to establish boundaries, allowing the client to solely determine them may not always be in their best interest.
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