A client receiving risperidone reports severe muscle stiffness at 1030. By 1200, the client has difficulty swallowing food and is drooling. The client is diaphoretic. By 1600, vital signs are as follows Temperature 102.8 F pulse 110 beats/minute, respirations 26 breaths/minute, and blood pressure 150/90 mmHg.

What is the nurse's best analysis and action?

Institute reverse isolation

Withhold the next dose of medication

Begin high protein, high cholesterol diet

Notify health care provider stat

Answer and Explanation

The Correct Answer is D

A) Incorrect. Reverse isolation is not indicated in this situation. The client's symptoms are likely due to a side effect of the medication, not an infectious process.

B) Incorrect. While it may be necessary to withhold the next dose of medication, the client's symptoms require more immediate attention.

C) Incorrect. The client's symptoms are indicative of a serious adverse reaction, and dietary changes would not address the issue.

D) Correct. The client's symptoms, including severe muscle stiffness, difficulty swallowing, drooling, diaphoresis, and elevated vital signs, are indicative of neuroleptic malignant syndrome (NMS), a potentially life-threatening side effect of antipsychotic medications like risperidone.
The nurse should notify the healthcare provider immediately for further guidance and intervention.

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Correct Answer is B

Explanation

A. Haloperidol is a first-generation antipsychotic and may not be as effective in addressing the negative symptoms (e.g., apathy, poverty of thought) as second-generation antipsychotics.
B. Olanzapine is a second-generation antipsychotic known to be effective in treating both positive and negative symptoms of schizophrenia.
C. Diphenhydramine is not typically used as a primary treatment for schizophrenia.
D. Chlorpromazine is a first-generation antipsychotic and may not be as effective in addressing the negative symptoms as second-generation antipsychotics.

A. Delusions of reference B. Tangentiality C. Neologism D. Loose associations

Correct Answer is D

Explanation

A) Incorrect. Delusions of reference involve a belief that everyday events, objects, or other people have a particular and unusual significance. This is not described in the scenario.

B) Incorrect. Tangentiality is a thought disorder where the individual goes off on tangents and never returns to the original point or idea. This is not described in the scenario.

C) Incorrect. Neologism refers to the creation of new words or phrases that have meaning only to the person using them. This is not described in the scenario.

D) Correct. Loose associations are characterized by a disruption in the logical progression of thought, where thoughts become disorganized and may seem unrelated or loosely connected.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse is obtaining the mental health history of a newly admitted client diagnosed with schizophrenia. The client's family reports the client is hearing voices and cannot stay focused on the topic of a discussion. Which thought disturbance is the client demonstrating?

Correct Answer is D

Explanation

The nurse is admitting a client with a dual diagnosis of major depressive disorder and alcohol abuse. What is the primary intervention?

The nurse is caring for a client with poor self-esteem. What intervention would be important for the nurse to include in the plan of care?

A nurse is providing teaching for a client who has schizophrenia and a new prescription for risperidone. Which of the following statements should the nurse include in the teaching?

The nurse states in report that the client is experiencing positive symptoms of schizophrenia. What symptoms would the nurse receiving report expect to observe?

A client asks the nurse to give her information regarding the detoxification process of alprazolam. What is the best response by the nurse?

A client diagnosed with major depressive disorder with psychotic features hears voices commanding self harm. The client refuses to commit to developing a plan for safety. What should be the nurse's priority intervention at this time?

A client with chronic alcoholism has been found to have Wernicke encephalopathy. What is this irreversible complication characterized by?

Benztropine is ordered as needed (PRN) for a client taking haloperidol after being diagnosed with schizoaffective disorder. Which of the following assessments by the nurse would indicate a need for this medication?