The nurse is continuing to care for the client in the emergency department (ED). 

Exhibits

The nurse should monitor the client for which of the following based on the result of the client's laboratory test? Select all that apply.

Rationale:

• Heart rate: The client's heart rate has increased to 124 beats per minute, which is significantly higher than normal. This tachycardia could be a sign of neuroleptic malignant syndrome (NMS), a potentially life-threatening reaction to antipsychotic medications like haloperidol.
• Temperature: The client's elevated temperature of 39.5°C (103.1°F) is concerning and could be indicative of NMS, which often presents with hyperthermia as one of its hallmark symptoms. NMS is a medical emergency that requires immediate attention.

Rationale for incorrect choices:

• Vision report: The client's report of blurry vision may be a side effect of haloperidol, but it is not typically considered a life-threatening reaction. It should be monitored but does not indicate an immediate crisis.
• Blood pressure: While the blood pressure is slightly low, it is not as critical as the combination of elevated heart rate and temperature. The low blood pressure would require monitoring but is not immediately indicative of a life-threatening reaction.
• Mouth report: Dry mouth is a common side effect of many medications, including antipsychotics like haloperidol. While uncomfortable, it is not a life-threatening condition.
• Respiratory rate: The respiratory rate of 22/min is within normal limits and does not indicate any immediate concerns related to the medication. It should be monitored but does not raise a red flag for a life-threatening reaction.

A. "I hope I can prevent them from being hospitalized again.": While this shows concern, it suggests that the client feels responsible for preventing hospitalization, which can be an unrealistic expectation and reflects potential caregiver burden rather than acceptance.
B. "I will do my best even though I feel tired all of the time.": This reflects exhaustion and a sense of being overwhelmed, but it does not necessarily indicate acceptance of the role change. The client may still be struggling with the emotional toll of caregiving.
C. "I would like to have information about support groups.": This statement indicates a proactive approach to managing the caregiving role, which suggests that the client is beginning to accept the changes and is seeking resources to help cope. It shows openness to support and adaptation to the role.
D. "It is hard to make time for my children and my family member.": This indicates that the client is struggling with balancing caregiving and family responsibilities, which suggests difficulty in fully accepting the new caregiving role.