A patient prescribed an antipsychotic medication develops a high ...

[EY67]

A patient prescribed an antipsychotic medication develops a high fever, unstable blood pressure, and muscle rigidity. Her next dose of medication is due. The nurse should:
 
  a. Administer the medication and monitor the vital signs every 4 hours.
  b. Give a lower dose of the medication for 24 hours and monitor the blood pressure.
  c. Prepare to administer a prn dose of the anticholinergic drug benztropine (Co-gentin).
  d. Hold the medication and immediately describe the patient's symptoms to the doctor.

Question 2

Which interventions will the nurse implement to preserve milieu safety when a patient becomes agitated? Select all that apply.
 
  a. Project confidence and control.
  b. Provide a show of force when appropriate.
  c. Ask the agitated patient why they are feeling so aggressive.
  d. Move to within 5 feet of the patient to help contain their movement.
  e. Provide the patient with several options as means of de-escalating the crisis.

[AaaA]

Answer to Question 1

ANS: D
These symptoms could be related to a possibly fatal disorder called neuroleptic malignant syndrome (NMS), and the nurse should hold the medication and contact the doctor immedi-ately. The other options are inappropriate in light of the seriousness of the situation.

Answer to Question 2

ANS: A, B, E
The correct options demonstrate that the staff is in control without unnecessarily challenging the patient. Asking why' is often interpreted as being challenging and often serves to future agitate the patient. Eight feet is considered to be the therapeutic distance between patient and staff in this type of situation.