A nurse in an emergency department is assessing a client who has been taking haloperidol for 3 months. The client has a temperature of 39.5* C (103.4° F), blood pressure of 150/110 mm Hg, and muscle rigidity. Which of the following complications should the nurse suspect?
Akathisia
Neuroleptic malignant syndrome
Tardive dyskinesia
Agranulocytosis
The Correct Answer is B
A. Akathisia: Akathisia is characterized by restlessness and an inability to sit still. While it can be a side effect of antipsychotic medications like haloperidol, it does not present with fever, hypertension, and muscle rigidity, as described in the scenario.
B. Neuroleptic malignant syndrome (NMS): NMS is a potentially life-threatening condition associated with antipsychotic medications like haloperidol. It is characterized by hyperthermia, autonomic dysfunction (e.g., hypertension), altered mental status, and severe muscle rigidity. The client's symptoms of fever, elevated blood pressure, and muscle rigidity are consistent with NMS.
C. Tardive dyskinesia: Tardive dyskinesia is a movement disorder characterized by involuntary, repetitive movements of the face, tongue, and other body parts. It is a long-term side effect of antipsychotic medications and typically develops after prolonged use, unlike the acute onset seen in the scenario.
D. Agranulocytosis: Agranulocytosis is a rare but serious side effect of antipsychotic medications, characterized by a severe reduction in white blood cell count, leading to an increased risk of infection. The symptoms described in the scenario are not consistent with agranulocytosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Prepare for gastric lavage due to an extremely elevated lithium level.
This option is incorrect. A lithium level of 1.0 mEq/L is within the therapeutic range for treating bipolar disorder or other mood disorders. Gastric lavage (stomach pumping) is not indicated for this level of lithium concentration.
B. Check the client's medication record to assess whether the client has been refusing her lithium.
This option is not directly relevant to the client's current lithium level of 1.0 mEq/L. While it's important to monitor medication adherence, the client's lithium level is within the therapeutic range, so there is no immediate concern about refusal or non-adherence.
C. Administer the morning dose of lithium.
This option is correct. With a lithium level of 1.0 mEq/L, which falls within the therapeutic range for treating bipolar disorder, the nurse should proceed with administering the morning dose of lithium as prescribed. It's important to maintain therapeutic lithium levels to effectively manage the client's condition.
D. Hold the medication and assess for early manifestations of toxicity.
This option is incorrect. With a lithium level of 1.0 mEq/L, there is no indication to hold the medication or suspect early manifestations of toxicity. Monitoring for lithium toxicity is important, but it's not warranted in this scenario where the lithium level is within the therapeutic range.
Correct Answer is ["B","C","D","E"]
Explanation
Answer: (B, C, D, E)
Rationale:
A) Damp dressing: A damp dressing around the IV site is typically indicative of a leaking IV or infiltration, where fluid escapes from the vein into the surrounding tissue. This finding is not directly related to phlebitis, which is inflammation of the vein.
B) Warmth at insertion site: Warmth at the insertion site is a common sign of phlebitis. The inflammation of the vein causes increased blood flow to the area, leading to localized warmth. This symptom is a key indicator that the IV site may be irritated or infected.
C) Streak formation: Streak formation, often seen as a red line running along the vein above the IV site, is a classic sign of phlebitis. It indicates inflammation and irritation spreading along the vein, which can occur due to the presence of the IV catheter.
D) Throbbing: Throbbing pain or discomfort at the IV site is another sign of phlebitis. The inflammation of the vein can cause pain that may be constant or increase with movement or palpation, indicating irritation or potential damage to the vessel.
E) Erythema: Erythema, or redness at the IV site, is a hallmark sign of phlebitis. The inflammation results in redness around the insertion area, which may spread along the vein, further indicating the presence of irritation or infection at the site.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.