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 B
Explanation
A. Dilute the medication with sterile water before injecting: Phenytoin should not be diluted before administration because it may cause precipitation or crystallization of the drug, leading to potential adverse effects such as tissue irritation or embolism.
B. Administer the medication over 1 min: Phenytoin should be administered slowly over 1 to 2 minutes to reduce the risk of adverse effects such as hypotension or cardiac arrhythmias. Rapid infusion can lead to cardiovascular collapse.
C. Slow the injection if the medication crystallizes: If the medication crystallizes, the nurse should stop the injection immediately and flush the IV line with normal saline. However, preventing crystallization by administering the medication slowly over the recommended time is preferable.
D. Follow the IV injection with sterile water: Following the IV injection with sterile water is not a standard practice for administering phenytoin. Instead, the nurse should follow institutional guidelines for flushing the IV line after medication administration, typically with normal saline.
Correct Answer is D
Explanation
Children can often be resistant to taking medication, but offering them choices and involving them in the process can help promote cooperation. Here's the rationale for each option:
A. Tell the child it is candy: This strategy involves deception and can lead to trust issues if the child discovers the truth. It's not ethical or recommended to lie to a child about medication.
B. Tell the child he will have to have a shot instead: Threatening the child with a shot is coercive and can cause fear and anxiety. It's not an appropriate or therapeutic approach to encourage cooperation.
C. Hide the medication in a large dish of ice cream: While hiding medication in food may work for some children, it's important to ensure that the child consumes the entire dose. Additionally, it's essential to check with the healthcare provider or pharmacist to confirm that the medication can be taken with food. However, this approach may not address the underlying issue of the child's resistance to taking medication.
D. Offer the child a choice of taking the medication with juice or water: Offering the child a choice empowers them and gives them some control over the situation. By allowing the child to choose how they take the medication, they may feel more comfortable and cooperative. This approach respects the child's autonomy and can be an effective way to encourage cooperation while ensuring the medication is taken as prescribed.
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