A nurse is preparing to administer lactulose 30 g PO four times daily to a client who has portal-systemic encephalopathy. The amount available is lactulose al solution 10 g/15 ml. How many ml. should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)

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.

A. Levothyroxine for hypothyroidism: Levothyroxine is a thyroid hormone replacement that is considered safe in pregnancy. Proper management of maternal hypothyroidism is essential for fetal neurodevelopment, and it does not pose teratogenic risk.

B. Phenytoin for seizure disorder: Phenytoin is an antiepileptic drug associated with fetal hydantoin syndrome, which can cause congenital malformations such as cleft lip, cardiac defects, and skeletal abnormalities. It carries a known risk for teratogenic effects, requiring careful monitoring and potential consideration of alternative therapies.

C. Magnesium oxide for constipation: Magnesium oxide is generally safe for use during pregnancy for the treatment of constipation. It does not have teratogenic effects and is considered appropriate for maternal use when needed.

D. Ferrous sulfate for chronic anemia: Iron supplementation is essential in pregnancy to prevent maternal anemia and support fetal growth. Ferrous sulfate is safe and does not cause congenital malformations, making it an appropriate therapy during pregnancy.