A nurse in an emergency department is assessing a client who has been taking haloperidol for 3 months. The client has a temperature of 39.5* C (103.4° F), blood pressure of 150/110 mm Hg, and muscle rigidity. Which of the following complications should the nurse suspect?
Akathisia
Neuroleptic malignant syndrome
Tardive dyskinesia
Agranulocytosis
The Correct Answer is B
A. Akathisia: Akathisia is characterized by restlessness and an inability to sit still. While it can be a side effect of antipsychotic medications like haloperidol, it does not present with fever, hypertension, and muscle rigidity, as described in the scenario.
B. Neuroleptic malignant syndrome (NMS): NMS is a potentially life-threatening condition associated with antipsychotic medications like haloperidol. It is characterized by hyperthermia, autonomic dysfunction (e.g., hypertension), altered mental status, and severe muscle rigidity. The client's symptoms of fever, elevated blood pressure, and muscle rigidity are consistent with NMS.
C. Tardive dyskinesia: Tardive dyskinesia is a movement disorder characterized by involuntary, repetitive movements of the face, tongue, and other body parts. It is a long-term side effect of antipsychotic medications and typically develops after prolonged use, unlike the acute onset seen in the scenario.
D. Agranulocytosis: Agranulocytosis is a rare but serious side effect of antipsychotic medications, characterized by a severe reduction in white blood cell count, leading to an increased risk of infection. The symptoms described in the scenario are not consistent with agranulocytosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["75"]
Explanation
To calculate the infusion rate in mL/hr for total parenteral nutrition (TPN) we divide the total volume by the total infusion time.
Given: Total volume of TPN = 1800 mL Total infusion time = 24 hours
Infusion rate (mL/hr) = Total volume / Total infusion time
Substituting the given values: Infusion rate = 1800 mL / 24 hr ≈ 75 mL/hr
Rounded to the nearest whole number, the nurse should set the IV pump to deliver approximately 75 mL/hr of TPN.
Correct Answer is C
Explanation
A. Brain natriuretic peptide - Brain natriuretic peptide (BNP) is primarily used to diagnose heart failure and assess its severity. It is not routinely monitored in clients taking lithium.
B. Erythrocyte sedimentation rate - Erythrocyte sedimentation rate (ESR) is a nonspecific marker of inflammation and is not specifically related to lithium therapy monitoring.
C. Thyroid hormone assay - Monitoring thyroid function is essential in clients taking lithium because lithium can affect thyroid function, leading to hypothyroidism or hyperthyroidism. Therefore, checking thyroid hormone levels (T3, T4, and TSH) is important before administering lithium.
D. Liver function tests - While lithium can affect liver function in some cases, routine monitoring of liver function tests is not typically required for clients taking lithium. However, periodic liver function tests may be ordered if clinically indicated or if the client has underlying liver disease.
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