After applying a gait belt, the nurse assists a client with ambulation. While in the hallway, the client begins to fall. Which action should the nurse implement?

Rationale for correct choices:

• Pain: The client reports a pain level of 10/10 in the left arm, described as sharp and constant. Pain at this severity requires urgent management because uncontrolled pain can impair mobility. Immediate intervention for pain ensures comfort and supports further diagnostic and therapeutic procedures.

• Compartment syndrome: Findings of swelling, decreased sensation, coolness of the skin, and diminished left radial pulse suggest compromised circulation. These are classic warning signs of compartment syndrome, a limb-threatening complication caused by increased pressure within a muscle compartment.

Rationale for incorrect choices:

• Mobility: While the client’s long-term recovery will require mobility interventions, it is not the immediate priority in the acute emergency setting. Pain and neurovascular compromise take precedence over mobility at this stage because they directly affect safety and circulation.

• Swelling: Swelling is a significant concern, but it is a symptom rather than the priority need. Addressing pain and preventing complications such as compartment syndrome will indirectly reduce swelling by improving circulation and managing tissue injury.

• Venous thromboembolism: The client’s high BMI and reduced mobility put him at risk for VTE, but this is a longer-term complication. It does not outweigh the immediate need to manage severe pain and monitor for compartment syndrome, which can cause rapid tissue necrosis.

• Fat embolism syndrome: Fat embolism is a possible complication of long bone fractures, but there is no evidence here of a femoral fracture or respiratory distress. Although his weight and orthopedic history are risk factors, the current findings point more strongly toward compartment syndrome.

Rationale for Correct Choices:

• Extrapyramidal reaction: The client exhibits muscle stiffness, constant leg shaking, forward-backward rocking, and abnormal head positioning, all of which are hallmark signs of extrapyramidal symptoms (EPS) often caused by antipsychotic medications like haloperidol and chlorpromazine. Recognizing EPS early prevents further complications such as severe dystonia or Parkinsonism.

• Initiate one-on-one observation: Continuous observation is essential to ensure client safety, particularly due to agitation, abnormal movements, and risk of injury from dystonia or uncontrolled motor activity, which can be exacerbated in psychiatric patients on antipsychotics.

• Education on administration and side effects of haloperidol: Teaching the client and caregivers about haloperidol’s potential side effects, including EPS, akathisia, and tardive dyskinesia, enhances adherence, promotes early reporting of adverse effects, and supports safe medication management.

• Gait and muscle strength: Monitoring gait and muscle strength allows the nurse to track the severity and progression of extrapyramidal symptoms, assess mobility limitations, and evaluate the effectiveness of interventions like anticholinergic medications or dosage adjustments.

• Improvement in symptoms: Observing improvement in EPS or agitation provides measurable evidence that interventions are effective, guiding ongoing care and any necessary modifications to therapy or dosing.

Rationale for Incorrect Choices:

• Mucositis: Mucositis involves inflammation and ulceration of the mucous membranes, typically related to chemotherapy or radiation therapy, and is not consistent with this client’s current presentation of abnormal motor activity and psychiatric symptoms.

•Hypertensive crisis: The client’s blood pressure is within a normal to mildly elevated range, and there are no signs of acute end-organ damage, so hypertensive crisis is unlikely in this scenario.

• Parkinson’s Disease: Parkinsonism is a chronic neurodegenerative disorder characterized by resting tremor, bradykinesia, and rigidity, not acute onset EPS triggered by antipsychotic use in a young adult with schizophrenia.

• Institute oral hygiene to prevent candidiasis: Oral hygiene is generally important but does not address the acute neurological side effects of antipsychotic medications, making it nonessential for EPS management.

• Immediate dietician consult: While nutrition is important, it is not immediately relevant for extrapyramidal symptoms and does not address the urgent motor complications caused by antipsychotics.

• Administer antihypertensive: The client’s blood pressure is not critically elevated, and there are no indications of hypertensive emergency, so antihypertensive therapy is unnecessary.

• Blood pressure: Monitoring blood pressure is routine but not directly related to tracking extrapyramidal symptoms or response to antipsychotic therapy in this case.

• Swallowing: While dysphagia can occur in severe EPS, this client does not currently present with swallowing difficulties, making it less critical to monitor compared to gait and muscle strength.