A nurse is administering haloperidol to a client who has schizophrenia.
For which of the following adverse effects should the nurse monitor?
Gingival hyperplasia.
Muscle rigidity.
Polyuria.
Bruising.
The Correct Answer is B
Choice A rationale
Gingival hyperplasia is an overgrowth of gum tissue, often associated with certain medications like phenytoin or cyclosporine. It is caused by an increase in the number of fibroblasts and collagen deposition in the gingiva. Haloperidol, an antipsychotic, primarily affects dopamine receptors in the brain and does not cause gingival hyperplasia.
Choice B rationale
Haloperidol is a first-generation antipsychotic that blocks D2 dopamine receptors in the brain. This blockade, particularly in the nigrostriatal pathway, can lead to extrapyramidal symptoms (EPS) such as acute dystonia, parkinsonism (including muscle rigidity, bradykinesia, and tremor), and akathisia. Muscle rigidity is a common manifestation of drug-induced parkinsonism.
Choice C rationale
Polyuria is the excessive production of urine, often a symptom of diabetes mellitus or insipidus. It results from impaired water reabsorption in the kidneys. While some medications can affect fluid balance, haloperidol's primary pharmacological action on dopamine receptors does not directly induce polyuria as a typical adverse effect.
Choice D rationale
Bruising, or ecchymosis, results from bleeding under the skin, often due to trauma or coagulation disorders. It is caused by extravasation of blood from capillaries into surrounding tissues. Haloperidol does not affect coagulation factors or platelet function and is not associated with increased bruising as a direct adverse effect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Urinary retention is a potential adverse effect of opioid analgesics like meperidine due to their anticholinergic effects, which can relax the detrusor muscle and increase bladder sphincter tone. While important to monitor, it is not the most immediate life-threatening concern compared to respiratory depression.
Choice B rationale
Vomiting is a common gastrointestinal adverse effect of opioid analgesics, often due to stimulation of the chemoreceptor trigger zone in the brainstem. While distressing for the client and requiring intervention, it does not pose the immediate life-threatening risk that respiratory depression does.
Choice C rationale
Meperidine is an opioid agonist that acts on mu-opioid receptors in the central nervous system, including the brainstem respiratory centers. This can lead to dose-dependent respiratory depression by decreasing the sensitivity of these centers to carbon dioxide, making a depressed respiratory rate (normal range 12-20 breaths/min) the priority assessment for client safety.
Choice D rationale
Altered level of consciousness, such as drowsiness or sedation, is a common central nervous system effect of meperidine. While a significant finding indicating opioid effect, it is secondary in priority to respiratory depression, which directly impacts vital gas exchange and can quickly become life-threatening.
Correct Answer is A
Explanation
Choice A rationale
Laryngeal edema is a severe manifestation of an immediate hypersensitivity (Type I anaphylactic) reaction to penicillin. It involves swelling of the larynx, leading to airway obstruction, stridor, and difficulty breathing. This life-threatening condition requires immediate medical intervention, including epinephrine and airway management, making it the priority to monitor.
Choice B rationale
Urticaria, or hives, is a common cutaneous manifestation of a hypersensitivity reaction to penicillin. It involves transient, itchy wheals on the skin due to histamine release. While uncomfortable and requiring attention, it is typically not life-threatening unless accompanied by systemic symptoms like laryngeal edema or bronchospasm.
Choice C rationale
Epigastric distress, such as stomach upset or pain, is a common gastrointestinal adverse effect of oral penicillin V, often due to direct irritation of the gastric mucosa or altered gut flora. While it can cause discomfort, it is generally not a life-threatening condition and can often be managed with food or dose adjustment.
Choice D rationale
Maculopapular rash is a delayed hypersensitivity reaction to penicillin, usually appearing several days after initiation of therapy. It presents as flat, red areas with small raised bumps. While it indicates a drug allergy, it is generally not immediately life-threatening compared to acute airway compromise and resolves upon discontinuation of the medication.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.