A nurse is caring for a client who has schizophrenia and is taking risperidone (Risperdal). Which of the following findings should alert the nurse to a potential adverse effect of this medication? (Select all that apply.)
Fever
Polyuria
Muscle rigidity
Diaphoresis
Tremors.
Correct Answer : A,C,D,E
These are all possible signs of neuroleptic malignant syndrome (NMS), a rare but serious adverse effect of risperidone and other antipsychotic medications.
NMS is a life-threatening condition that requires immediate medical attention. It is characterized by fever, muscle rigidity, altered mental status, autonomic instability and elevated creatine kinase levels.
Choice B is wrong because polyuria is not a common side effect of risperidone. Polyuria can be caused by other conditions such as diabetes mellitus, diabetes insipidus or diuretic use.
Normal ranges for vital signs and laboratory values are as follows:
• Temperature: 36.5°C to 37.5°C (97.7°F to 99.5°F)
• Heart rate: 60 to 100 beats per minute
• Blood pressure: 120/80 mm Hg or lower
• Respiratory rate: 12 to 20 breaths per minute
• Oxygen saturation: 95% or higher
• Creatine kinase: 22 to 198 U/L for males and 10 to 171 U/L for females
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Hydroxyzine (Vistaril) is an antihistamine that can cause drowsiness and sedation as side effects.Therefore, the client should avoid activities that require alertness and coordination while taking this medication.
Choice B is wrong because hydroxyzine can be taken with or without food.Taking it on an empty stomach does not increase absorption.
Choice C is wrong because hydroxyzine can cause dry mouth as a side effect, but the client does not need to drink plenty of fluids or suck on hard candy to prevent it.These measures may help relieve the discomfort of dry mouth, but they are not necessary instructions for taking hydroxyzine.
Choice D is wrong because hydroxyzine does not cause urinary retention or difficulty urinating as side effects.These are signs of anticholinergic toxicity, which can occur with other medications such as tricyclic antidepressants or antipsychotics.
Correct Answer is ["A","C","E"]
Explanation
The client should avoid foods that are high in tyramine while taking phenelzine, which is a monoamine oxidase inhibitor (MAOI) for depression. Tyramine can cause a hypertensive crisis when combined with MAOIs.
Choice B is wrong because shrimp is not high in tyramine and can be safely consumed by the client.
Choice D is wrong because raisins are not high in tyramine and can be safely consumed by the client.
Some examples of foods that are high in tyramine are avocado, cheddar cheese, pepperoni, aged meats, smoked fish, soy sauce, sauerkraut, beer, and red wine.
The normal range for blood pressure is less than 120/80 mmHg.A hypertensive crisis is defined as a systolic blood pressure of 180 mmHg or higher or a diastolic blood pressure of 120 mmHg or higher.The client should monitor their blood pressure regularly and report any signs of a hypertensive crisis, such as severe headache, chest pain, blurred vision, nausea, or confusion.
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