A nurse is assessing a client who is receiving treatment with multiple antipsychotic medications and who suddenly became ill.

Findings include blood pressure changes, hyperpyrexia, and diaphoresis.

The nurse should recognize that which of the following adverse effects may be occurring?

Pseudoparkinsonism.

Neuroleptic malignant syndrome.

Acute dystonia.

Tardive dyskinesia.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Pseudoparkinsonism is a side effect of antipsychotic medications that mimics the symptoms of Parkinson’s disease, such as tremors and rigidity. It does not typically cause hyperpyrexia or diaphoresis.

Choice B rationale:

Neuroleptic malignant syndrome is a rare but serious side effect of antipsychotic medications. It can cause severe fever (hyperpyrexia), unstable blood pressure, and heavy sweating (diaphoresis)4.

Choice C rationale:

Acute dystonia is a condition of sudden, involuntary muscle contractions. It does not typically cause hyperpyrexia or diaphoresis.

Choice D rationale:

Tardive dyskinesia is a side effect of long-term use of antipsychotic medications, causing involuntary movements, especially around the mouth. It does not typically cause hyperpyrexia or diaphoresis.

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Correct Answer is D

Explanation

Choice A rationale:
While educating the client about policies upon admission to the unit is important, it may not have the greatest impact on both the management of care and on milieu environment.
Choice B rationale:
Instructing the client that intrusive behaviors are not appropriate is important, but it may not have the greatest impact on both the management of care and on milieu environment.
Choice C rationale:
Ensuring that the client’s medication therapy is administered in a timely manner is crucial, but it may not have the greatest impact on both the management of care and on milieu environment.
Choice D rationale:
Setting and maintaining consistent unit policies that are enforced by all staff can create a stable and predictable environment, which can have a significant impact on both the management of care and on milieu environment.

A. "I know you hear the voices, but I do not.”. B. "The voices are part of your illness.”. C. "How often do you hear the voices?". D. "What are the voices telling you?".

Correct Answer is D

Explanation

Choice A rationale:

While acknowledging the voices can be part of therapeutic communication, it’s not the first response a nurse should make.

Choice B rationale:

Telling the client that the voices are part of their illness can be helpful, but it’s not the first response a nurse should make.

Choice C rationale:

Asking about the frequency of the voices can be part of the assessment, but it’s not the first response a nurse should make.

Choice D rationale:

Asking what the voices are saying can help assess if the client is experiencing command hallucinations, which could pose a safety risk.

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A nurse is assessing a client who is receiving treatment with multiple antipsychotic medications and who suddenly became ill. Findings include blood pressure changes, hyperpyrexia, and diaphoresis. The nurse should recognize that which of the following adverse effects may be occurring?

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Naxlex Comprehensive Predictor Exams

Which nursing intervention will have the greatest impact on both the management of care and on milieu environment when considering the clients diagnosed with bipolar disorder?

Correct Answer is D

Explanation

A nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following responses should the nurse make first?

Correct Answer is D

Explanation

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A nurse is assessing a client who is receiving treatment with multiple antipsychotic medications and who suddenly became ill.

Findings include blood pressure changes, hyperpyrexia, and diaphoresis.

The nurse should recognize that which of the following adverse effects may be occurring?