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 C

Explanation

A) Incorrect. This statement does not provide relevant information about the medication or potential risks.

B) Incorrect. This statement is not accurate and may cause unnecessary concern or confusion for the client.

C) Correct. Adolescents and young adults prescribed with antidepressant medications should be informed about the potential increased risk of suicidal thoughts or behaviors, especially in the early stages of treatment. This information is important for the client's safety and allows for appropriate monitoring.

D) Incorrect. Doubling the dose if a dose is missed is not a safe or appropriate practice. The client should be instructed on what to do if they miss a dose according to their healthcare provider's instructions.

A. "Why do you want to kill yourself?" B. "Do you have access to medications?" C. "Have you been taking drugs and alcohol?" D. "Did something happen with your parents?"

Correct Answer is B

Explanation

A) Incorrect. While understanding the reasons behind the suicidal thoughts is important, in this immediate situation, assessing access to means (medications) is crucial.

B) Correct. This question assesses the immediate risk by determining if the friend has access to the means (medications) to carry out the overdose.

C) Incorrect. While substance use is a risk factor, it may not directly address the immediate threat of overdose with pills.

D) Incorrect. While family issues can contribute to emotional distress, the most pressing concern is the immediate risk of overdose.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A physician has prescribed an antidepressant medication for a 15yearold client. Which statement would be appropriate for inclusion in medication teaching?

Correct Answer is C

Explanation

An adolescent tells the school nurse, "My friend threatened to take an overdose of pills." The nurse talks to the friend who verbalized the suicide threat. What is the most critical question for the nurse to ask?

Correct Answer is B

Explanation

A nurse is caring for a client who exhibits manifestations of major depressive disorder. The provider wants to rule out any other medical conditions that may be contributing or causing the symptoms. Which diagnostic test should the nurse expect to be ordered?

When assessing a client immediately following electroconvulsive therapy (ECT), the nurse expects what side effect in a client?

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

What are the possible physiological changes in the brain of a client diagnosed with Alzheimer's disease? (Select all that apply)

A client is hospitalized following a suicide attempt after breaking up with her significant other. The client says to the nurse, "When I get out of here, I'm going to try this again, and next time I'll get it right?" Which is the best response by the nurse?

The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse would monitor for which symptoms?

A female client staggers to day treatment smelling strongly of alcohol. She uses the defense mechanism "rationalization" when approached by the nurse and questioned about her recent alcohol consumption. How is this expressed?