A nurse is caring for a client.

Exhibits

Which of the following actions should the nurse expect to take? Select all that apply.

Administer diphenhydramine 50 mg IM.

Arrange for transport of the client to the nearest emergency department

Apply cool, wet washcloths to the client's forehead and axilla.

Administer fluphenazine decanoate in the client's deltoid.

Instruct the client to discontinue risperidone

Answer and Explanation

Correct Answer : A,B,C

A. Administer diphenhydramine 50 mg IM: The client exhibits signs of neuroleptic malignant syndrome (NMS), including hyperthermia, autonomic instability, altered mental status, and muscle rigidity. Diphenhydramine can help manage extrapyramidal symptoms and muscle rigidity while stabilizing the client, making it an appropriate intervention in the acute phase.

B. Arrange for transport of the client to the nearest emergency department: NMS is a life-threatening medical emergency requiring immediate hospitalization for monitoring, intravenous fluids, and intensive management. The client’s elevated temperature, tachycardia, and altered mental status necessitate urgent transfer to a facility for providing acute care.

C. Apply cool, wet washcloths to the client's forehead and axilla: Hyperthermia is a critical component of NMS. Applying cool, wet washcloths provides non-pharmacologic fever management to reduce core body temperature while awaiting transport and additional treatment interventions. This helps prevent further complications such as organ failure.

D. Administer fluphenazine decanoate in the client's deltoid: Administering antipsychotics is contraindicated during NMS because these medications are the precipitating agents. Giving fluphenazine could worsen symptoms, increase rigidity, and exacerbate autonomic instability, so it must be avoided.

E. Instruct the client to discontinue risperidone: While antipsychotics should be discontinued in NMS, simply instructing the client to stop taking risperidone is insufficient. Immediate medical intervention and supervised discontinuation in a hospital setting are required due to the risk of rapid deterioration and life-threatening complications.

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Correct Answer is C

Explanation

A. Shakiness: Shakiness is typically a manifestation of hypoglycemia, resulting from activation of the sympathetic nervous system. It occurs when blood glucose drops below normal levels, not with hyperglycemia, so it is not associated with a glucose level of 265 mg/dL.

B. Confusion: Confusion can occur with both severe hyperglycemia and hypoglycemia, but it is more pronounced in extreme elevations of blood glucose or in hyperosmolar hyperglycemic states. A level of 265 mg/dL may not yet cause marked cognitive changes in all clients.

C. Thirst: Hyperglycemia causes osmotic diuresis, leading to fluid loss and dehydration, which triggers excessive thirst (polydipsia). This is a common and early clinical manifestation associated with elevated blood glucose levels such as 265 mg/dL.

D. Diaphoresis: Diaphoresis, or excessive sweating, is primarily a symptom of hypoglycemia caused by adrenergic stimulation. It is not a typical manifestation of hyperglycemia and is unlikely to occur with a blood glucose of 265 mg/dL.

A. Report of a chronic dull ache in the eyes B. Bilateral redness of the sclerae C. Increased opacity of the lens of the eye D. Report of seeing halos around lights

Correct Answer is C

Explanation

A. Report of a chronic dull ache in the eyes: Eye discomfort or ache is more commonly associated with conditions like glaucoma or eye strain. Cataracts are typically painless and do not produce chronic dull ache.

B. Bilateral redness of the sclerae: Redness of the sclera indicates inflammation or infection, such as conjunctivitis, and is not a characteristic sign of cataracts.

C. Increased opacity of the lens of the eye: Cataracts are defined by a clouding or opacity of the eye’s lens, which interferes with light transmission and vision. This physical change in the lens is the hallmark finding in cataract development.

D. Report of seeing halos around lights: Seeing halos is more commonly associated with glaucoma due to increased intraocular pressure, rather than cataracts. While cataracts may cause blurred or dim vision, halos are not the primary symptom.

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A nurse is caring for a client. Exhibits Which of the following actions should the nurse expect to take? Select all that apply.

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A nurse is caring for a client.

Exhibits

Which of the following actions should the nurse expect to take? Select all that apply.