A client receiving risperidone (Risperdal) reports severe muscle ...

[Mr3Hunna]

A client receiving risperidone (Risperdal) reports severe muscle stiffness mid-morning. During
  lunch he has difficulty swallowing food and is noted to drool.
 
  When vital signs are taken at 4 PM he
  is noted to be diaphoretic, with a temperature elevation of 38.4 C, pulse of 110 beats/min, and
  blood pressure of 150/90 mm Hg. The nurse should suspect
  a. agranulocytosis and institute reverse isolation.
  b. cholestatic jaundice and begin a high-protein, high-cholesterol diet.
  c. tardive dyskinesia and withhold the next dose of medication.
  d. neuroleptic malignant syndrome and notify physician stat.

Question 2

The client's nursing diagnosis is disturbed sleep pattern related to anxiety. The desired outcome is
  that client will sleep for a minimum of 5 hours nightly by October 31 .
 
  On November 1 review of
  sleep data for the 6 days of hospitalization shows the client sleeps an average of 4 hours nightly and
  takes a 2-hour afternoon nap. The outcome can be evaluated as
  a. consistently demonstrated.
  b. often demonstrated.
  c. sometimes demonstrated.
  d. never demonstrated.

[johnharpe]

Answer to Question 1

D
Taking an antipsychotic medication coupled with the presence of extrapyramidal symptoms such
severe muscle stiffness and difficulty swallowing, hyperpyrexia, and autonomic symptoms (pulse
elevation) suggest neuroleptic malignant syndrome, a medical emergency. The symptoms given in
the scenario are not consistent with the medical problems listed in options A, B, or C.

Answer to Question 2

ANS: D
Although the client is sleeping 6 hours daily, the total is not in one uninterrupted session at night.
Therefore the outcome must be evaluated as never demonstrated.

[Mr3Hunna]

Gracias!

[yeungji]

TYSM