A nurse is caring for a client.
Which of the following actions should the nurse expect to take? Select all that apply.
Administer diphenhydramine 50 mg IM.
Arrange for transport of the client to the nearest emergency department
Apply cool, wet washcloths to the client's forehead and axilla.
Administer fluphenazine decanoate in the client's deltoid.
Instruct the client to discontinue risperidone
Correct Answer : A,B,C
A. Administer diphenhydramine 50 mg IM: The client exhibits signs of neuroleptic malignant syndrome (NMS), including hyperthermia, autonomic instability, altered mental status, and muscle rigidity. Diphenhydramine can help manage extrapyramidal symptoms and muscle rigidity while stabilizing the client, making it an appropriate intervention in the acute phase.
B. Arrange for transport of the client to the nearest emergency department: NMS is a life-threatening medical emergency requiring immediate hospitalization for monitoring, intravenous fluids, and intensive management. The client’s elevated temperature, tachycardia, and altered mental status necessitate urgent transfer to a facility for providing acute care.
C. Apply cool, wet washcloths to the client's forehead and axilla: Hyperthermia is a critical component of NMS. Applying cool, wet washcloths provides non-pharmacologic fever management to reduce core body temperature while awaiting transport and additional treatment interventions. This helps prevent further complications such as organ failure.
D. Administer fluphenazine decanoate in the client's deltoid: Administering antipsychotics is contraindicated during NMS because these medications are the precipitating agents. Giving fluphenazine could worsen symptoms, increase rigidity, and exacerbate autonomic instability, so it must be avoided.
E. Instruct the client to discontinue risperidone: While antipsychotics should be discontinued in NMS, simply instructing the client to stop taking risperidone is insufficient. Immediate medical intervention and supervised discontinuation in a hospital setting are required due to the risk of rapid deterioration and life-threatening complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Suppresses the cough reflex: Scheduled pain medication is not intended to suppress coughing, as cough suppression can actually be harmful after thoracic surgery. Clients need to maintain an effective cough to clear secretions and prevent atelectasis or pneumonia. Suppressing this reflex could increase the risk of postoperative respiratory complications.
B. Decreases the level of anxiety: Although adequate pain control can help reduce anxiety, this is not the primary goal in the immediate postoperative period following thoracic surgery. Anxiety relief is a secondary benefit, but it does not directly address the major respiratory risks associated with this type of surgery.
C. Reduces the respiratory rate: Reducing the respiratory rate is not desirable in a postoperative thoracic surgery client. Opioids can depress respirations, which can compromise oxygenation and ventilation. A lower respiratory rate increases the risk of CO₂ retention and postoperative complications.
D. Facilitates deep breathing: Providing pain medication on a schedule ensures that the client can breathe deeply and participate in necessary pulmonary hygiene measures. Thoracic surgery causes significant incisional pain that limits chest expansion, making deep breathing difficult without adequate analgesia.
Correct Answer is D
Explanation
A. A client who is 2 days postoperative following a colon resection: This client may have complex postoperative needs, including management of surgical drains, potential complications such as infection or anastomotic leakage, and advanced pain management. These require specialized knowledge and experience, making it less appropriate for a float nurse.
B. A client who has tuberculosis and is on airborne precautions: Care for a client with airborne precautions requires strict adherence to infection control protocols, including use of negative pressure rooms and N95 respirators. A float nurse from postpartum may not be fully trained in airborne isolation procedures, making this assignment unsafe.
C. A client who has a head injury and requires neurological checks every 4 hr: Frequent neurological assessments and the ability to detect subtle changes in neuro status require specialized knowledge and experience in neuro care. A float nurse from postpartum may not have the necessary training to safely monitor and respond to neurological changes.
D. A client who is 1 day postoperative following a transurethral resection of the prostate: This client typically requires routine postoperative monitoring, including vital signs, intake and output, and catheter care, which are within the skill set of a float nurse with general nursing experience. The care is predictable and does not require specialized care knowledge.
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