A client who has been taking haloperidol for several weeks presents with restlessness, constant pacing, and inability to sit still. What is the most likely extrapyramidal symptom the client is experiencing?

Choice A reason: Recent weight gain, as reported by the spouse, is not a specific symptom of acute mania. It may result from medication side effects or lifestyle factors but does not reflect the heightened dopaminergic activity in the brain associated with mania, such as elevated mood, energy, or disorganized thinking.

Choice B reason: Dressing in all black may reflect personal style or cultural factors but is not a diagnostic criterion for acute mania. Mania involves neurochemical imbalances, particularly elevated dopamine, leading to symptoms like grandiosity or impulsivity, not specific clothing choices, making this an irrelevant finding.

Choice C reason: Hearing voices suggesting novel-writing indicates auditory hallucinations, more characteristic of schizophrenia or psychotic disorders than bipolar mania. While mania may include grandiosity, it typically lacks hallucinations unless severe, making this less specific to the admitting diagnosis of acute mania.

Choice D reason: Disorganized speech is a hallmark of acute mania, reflecting accelerated thought processes due to increased dopamine and norepinephrine activity in the brain. It manifests as tangential or rapid speech, impairing communication, and is a key diagnostic feature of bipolar disorder’s manic phase, supporting the admitting diagnosis.

Choice A reason: Asking the client to blow their nose is contraindicated in basal skull fractures, as it can increase intracranial pressure or force bacteria into the cranial cavity, risking meningitis. The clear drainage may be cerebrospinal fluid (CSF), and blowing the nose could exacerbate the fracture-related dural tear.

Choice B reason: Suctioning the nostril is dangerous in basal skull fractures, as it may introduce infection or worsen a dural tear if the drainage is CSF. The negative pressure could disrupt intracranial structures, increasing complications like meningitis or brain herniation, making this an inappropriate first action.

Choice C reason: Testing the drainage for glucose is the priority, as clear nasal drainage in basal skull fractures may indicate CSF leakage due to a dural tear. CSF contains glucose, unlike nasal secretions, and a positive test confirms the need for urgent intervention to prevent infection or further neurological damage.

Choice D reason: Notifying the physician is important but secondary to confirming the nature of the drainage. Testing for glucose first identifies if the fluid is CSF, critical in basal skull fractures due to risks of meningitis or brain injury, ensuring the physician receives accurate, actionable information.