A nurse is collecting data from a client who is receiving multiple antipsychotic medications. The client exhibits muscle rigidity, hyperpyrexia, and diaphoresis. The nurse should identify that the client may be experiencing which of the following adverse effects?
Neuroleptic malignant syndrome
Acute dystonia
Tardive dyskinesia
Pseudoparkinsonism
The Correct Answer is A
Choice A reason: Neuroleptic malignant syndrome is a life-threatening reaction to antipsychotics characterized by muscle rigidity, high fever, and autonomic instability such as diaphoresis.
Choice B reason: Acute dystonia involves muscle spasms, usually of the face or neck, but not hyperpyrexia or diaphoresis.
Choice C reason: Tardive dyskinesia involves involuntary repetitive movements, often of the mouth or tongue, not systemic symptoms.
Choice D reason: Pseudoparkinsonism mimics Parkinson’s disease with tremors and rigidity but does not include hyperpyrexia or diaphoresis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Asking if the client has a plan to commit suicide is the priority intervention. It directly assesses the level of risk and helps determine the immediacy of danger. Suicide risk assessment is essential in borderline personality disorder, where impulsivity and self-harm are common.
Choice B reason: Assuming manipulation dismisses the seriousness of suicidal ideation. Even if manipulation is suspected, all suicidal statements must be taken seriously to ensure safety.
Choice C reason: Allowing the client to rest does not address the risk of suicide. Safety assessment must occur before any other intervention.
Choice D reason: Notifying family may be supportive but is not the immediate priority. The nurse must first assess the client’s risk and ensure safety before involving others.
Correct Answer is B
Explanation
Choice A reason: Encouraging the client to argue with voices reinforces the hallucination and is not therapeutic.
Choice B reason: Telling the client the hallucination is not real helps orient them to reality while maintaining empathy. It acknowledges their experience without validating the hallucination.
Choice C reason: Acting as if the hallucination is real reinforces psychosis and is inappropriate.
Choice D reason: Asking direct questions about the hallucination can increase focus on the false perception, worsening symptoms.
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