A nurse is caring for a client.
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
A. Dermatitis: Dermatitis affects the skin and is not associated with an increased risk of pneumonia. While skin integrity issues can lead to infections, they do not directly predispose a client to respiratory infections like pneumonia.
B. Type II diabetes mellitus: Diabetes mellitus impairs immune function and increases susceptibility to infections, including pneumonia. Hyperglycemia can impair neutrophil function, reducing the body’s ability to fight bacterial respiratory infections.
C. Smoking history: Smoking damages the respiratory epithelium and impairs mucociliary clearance, increasing the risk of bacterial colonization and infection in the lungs. A long-term smoking history is a well-established risk factor for pneumonia.
D. Hypothyroidism: Hypothyroidism can slow metabolism and affect multiple organ systems but is not a direct risk factor for pneumonia. While severe hypothyroidism may influence respiratory function, it is not considered a primary predisposing condition.
E. COPD: Chronic obstructive pulmonary disease leads to compromised lung function, impaired clearance of secretions, and increased susceptibility to respiratory infections. COPD is a significant risk factor for developing pneumonia, particularly in the lower lobes.
F. Hypertension: Hypertension affects cardiovascular health but does not directly impair immune function or pulmonary defenses. It is not considered a risk factor for pneumonia.
Correct Answer is B
Explanation
A.A gastric residual volume (GRV) of 250 mL is a finding that requires monitoring but typically does not require "immediate" intervention or the cessation of feeding. Current evidence-based guidelines often suggest that feedings should not be held unless the GRV exceeds 500 mL in a single measurement or if the client shows signs of intolerance (e.g., abdominal distension, nausea). While 250 mL indicates a slight delay in gastric emptying, it is not an acute emergency compared to the risk of aspiration from supine positioning.
B.The client is lying in a supine position: The client lying in a supine position requires immediate intervention. Clients receiving enteral feedings must have the head of the bed elevated to at least 30° to 45° at all times to prevent gastric reflux and aspiration. In a post-laryngectomy client, the risk is even higher because the anatomical changes to the upper airway make it easier for regurgitated feeding to enter the trachea. The nurse must immediately raise the head of the bed to ensure the client's safety.
C. The infusion pump for administering continuous feeding is turned off: The pump being turned off interrupts nutrition delivery, which is undesirable, but it does not pose an immediate risk to the client’s safety. Correcting the pump can be done after addressing more urgent issues.
D. The enteral feeding bag and tubing are not dated: Lack of dating increases the risk of infection due to prolonged use, but this is a routine safety concern and does not require immediate intervention compared with high gastric residual volumes that pose aspiration risk.
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