A nurse is assessing a client who has a prescription for haloperidol 0.5 mg PO three times daily. The medication administration record shows that the client received 5 mg per dose on the previous day. Which of the following manifestations is the nurse's priority to assess?
Muscle stiffness
Constipation
Dry mouth
Daytime drowsiness
The Correct Answer is A
A. Muscle stiffness can indicate extrapyramidal symptoms or early neuroleptic malignant syndrome, which are potentially life-threatening complications of haloperidol overdose. Prompt assessment and intervention are critical to prevent serious harm.
B. Constipation is a common side effect of haloperidol due to anticholinergic effects, but it develops gradually and is not immediately dangerous.
C. Dry mouth is also an anticholinergic side effect, causing discomfort but not posing an acute threat to the client’s safety.
D. Daytime drowsiness is a frequent effect of haloperidol, especially at high doses, but it is less immediately dangerous than neuromuscular complications.
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Related Questions
Correct Answer is C
Explanation
A. Magnesium 2.5 mEq/L: A magnesium level slightly above the normal range does not indicate an immediate need to discontinue clozapine, as this level is not related to the adverse effects of the drug.
B. Potassium 5.4 mEq/L: While elevated potassium levels can pose a health risk, this is not a direct indicator to discontinue clozapine. Potassium levels can be managed with other interventions.
C. WBC 2,500/mm³: Clozapine carries a risk of agranulocytosis, a condition where the white blood cell (WBC) count becomes dangerously low, leading to severe infection risk. A WBC count of 2,500/mm³ is below the normal range and indicates the need to discontinue clozapine immediately.
D. Sodium 134 mEq/L: A slightly low sodium level is not typically related to clozapine use and does not warrant discontinuation of the medication.
Correct Answer is A
Explanation
A. It is important to inform the client that nitrofurantoin can cause brown-colored urine as a harmless side effect and they should report this to their provider.
B. Nitrofurantoin is an antibiotic used to treat urinary tract infections and does not provide relief for peripheral nerve pain.
C. Nitrofurantoin should not be crushed because it can affect the medication's absorption and effectiveness.
D. While coughing is not a common side effect of nitrofurantoin, if the client develops a cough, it could indicate a serious reaction, so it is important to notify the provider. However, the primary teaching point for nitrofurantoin is regarding the urine discoloration.
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