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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Free Nursing Study Resources

Correct Answer is ["A","B"]

Explanation

A. "I don't have a problem, I can quit when, where and how I want to." This statement reflects denial and overconfidence, which are common obstacles to recovery. It suggests a lack of recognition of the seriousness of the addiction.

B. "I am not going to let my family and friends know I have an addiction and give them this burden." This statement indicates a reluctance to seek support from loved ones, which can hinder the recovery process. Keeping the addiction, a secret can lead to isolation and make it more
challenging to maintain recovery.

C. "I will start Alcoholic Anonymous meetings in two weeks when I am settled after discharge." This statement shows proactive planning and willingness to engage in support groups, which can be a positive step towards recovery.

D. "I know I am an addict, and it will take hard work and a higher power to help me." This statement reflects self-awareness and a recognition of the effort required for recovery. The
mention of a higher power suggests a willingness to engage in a spiritual or faith based approach to recovery, which can be beneficial for some individuals.

E. "I don't know how I am going to get through this but will take it one day at a time with my family." This statement acknowledges the challenges ahead and expresses a willingness to take recovery one step at a time with the support of family. It reflects a realistic and hopeful approach to the recovery process.

A. The client can accomplish all activities of daily living. B. The client is smiling and happy with their current lifestyle. C. The client has been experiencing hallucinations and delusions for less than six months. D. The client is euphoric with excessive energy.

Correct Answer is C

Explanation

A) Incorrect. The ability to accomplish activities of daily living is not specific to the diagnosis of schizophreniform disorder.

B) Incorrect. The client's emotional state or demeanor is not a specific indicator of schizophreniform disorder.

C) Correct. Schizophreniform disorder is characterized by the presence of hallucinations,
delusions, and other psychotic symptoms for less than six months. It is considered a provisional diagnosis while the condition is still in its early stages.

D) Incorrect. Euphoria and excessive energy are not specific features of schizophreniform disorder.

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Naxlex Comprehensive Predictor Exams

The nurse is teaching about obstacles to maintaining recovery. Which of the following statements would indicate to the nurse a greater risk for relapse? (Select all that apply.)

Correct Answer is ["A","B"]

Explanation

The nurse is admitting a client with the diagnosis of schizophreniform disorder. What should the nurse expect to find?

Correct Answer is C

Explanation

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

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?

While caring for a depressed client, a nurse would evaluate the need for suicide precautions under which circumstance?

A client with schizophrenia has begun a new prescription of clozapine. The nurse should assess the result of which laboratory study to monitor for adverse effects?

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?

Which statement provides the best rationale for why a nurse should closely monitor a severely depressed client during antidepressant therapy?

The mother of a 20yearold woman recently diagnosed with paranoid schizophrenia asks the nurse what causes schizophrenia. The nurse recognizes which of the following are implicated in the etiology of schizophrenia?

A client is admitted with tachycardia, hypertension, restlessness, agitation, and admits substance use. Which substance would be most likely to cause these symptoms?