The nurse working on a mental health unit is prioritizing nursing care activities because of a staffing shortage. One practical nurse (PN) is on the unit with the nurse, and another RN is expected to arrive within two hours. Clients need to be awakened and morning medications need to be prepared. Which plan is best for the nurse to implement?

Rationale for Correct Choices:

• Extrapyramidal reaction: The client exhibits muscle stiffness, constant leg shaking, forward-backward rocking, and abnormal head positioning, all of which are hallmark signs of extrapyramidal symptoms (EPS) often caused by antipsychotic medications like haloperidol and chlorpromazine. Recognizing EPS early prevents further complications such as severe dystonia or Parkinsonism.

• Initiate one-on-one observation: Continuous observation is essential to ensure client safety, particularly due to agitation, abnormal movements, and risk of injury from dystonia or uncontrolled motor activity, which can be exacerbated in psychiatric patients on antipsychotics.

• Education on administration and side effects of haloperidol: Teaching the client and caregivers about haloperidol’s potential side effects, including EPS, akathisia, and tardive dyskinesia, enhances adherence, promotes early reporting of adverse effects, and supports safe medication management.

• Gait and muscle strength: Monitoring gait and muscle strength allows the nurse to track the severity and progression of extrapyramidal symptoms, assess mobility limitations, and evaluate the effectiveness of interventions like anticholinergic medications or dosage adjustments.

• Improvement in symptoms: Observing improvement in EPS or agitation provides measurable evidence that interventions are effective, guiding ongoing care and any necessary modifications to therapy or dosing.

Rationale for Incorrect Choices:

• Mucositis: Mucositis involves inflammation and ulceration of the mucous membranes, typically related to chemotherapy or radiation therapy, and is not consistent with this client’s current presentation of abnormal motor activity and psychiatric symptoms.

•Hypertensive crisis: The client’s blood pressure is within a normal to mildly elevated range, and there are no signs of acute end-organ damage, so hypertensive crisis is unlikely in this scenario.

• Parkinson’s Disease: Parkinsonism is a chronic neurodegenerative disorder characterized by resting tremor, bradykinesia, and rigidity, not acute onset EPS triggered by antipsychotic use in a young adult with schizophrenia.

• Institute oral hygiene to prevent candidiasis: Oral hygiene is generally important but does not address the acute neurological side effects of antipsychotic medications, making it nonessential for EPS management.

• Immediate dietician consult: While nutrition is important, it is not immediately relevant for extrapyramidal symptoms and does not address the urgent motor complications caused by antipsychotics.

• Administer antihypertensive: The client’s blood pressure is not critically elevated, and there are no indications of hypertensive emergency, so antihypertensive therapy is unnecessary.

• Blood pressure: Monitoring blood pressure is routine but not directly related to tracking extrapyramidal symptoms or response to antipsychotic therapy in this case.

• Swallowing: While dysphagia can occur in severe EPS, this client does not currently present with swallowing difficulties, making it less critical to monitor compared to gait and muscle strength.

• Palpate and compare radial pulses: Assessing radial pulses bilaterally is essential after humeral fracture and surgical repair because neurovascular compromise is a major complication. Detecting differences in pulse quality can help identify impaired circulation or compartment syndrome early.

• Administer ondansetron 4 mg IV: The client reports nausea postoperatively, which can increase discomfort and risk for aspiration. Ondansetron is prescribed and effective in controlling nausea by blocking serotonin receptors in the gut and brain, making it an appropriate intervention.

• Perform range of motion: With a displaced humeral head/neck fracture and immediate postoperative status, range-of-motion exercises are contraindicated. Movement of the joint could disrupt fixation, increase bleeding, or worsen pain. Immobilization and stabilization are priorities.

• Provide morphine 2 mg IV push (IVP): The client currently reports a pain level of 0/10 due to the preoperative nerve block. The order is PRN for pain > 7. Administering it now would be inappropriate and increase the risk of respiratory depression.

• Inspect the bandage for drainage: Checking the surgical bandage is necessary to monitor for bleeding or excessive drainage, which may indicate complications such as hemorrhage or infection. Since the order specifies not to remove the dressing, visual inspection only is the correct approach.

• Check capillary refill on bilateral upper extremities: Capillary refill helps evaluate peripheral perfusion, which is critical after orthopedic surgery. Comparing both extremities provides baseline data and helps detect vascular compromise that could threaten limb viability.