Author Question: A client receiving risperidone (Risperdal) reports severe muscle stiffness mid-morning. During ... (Read 51 times)

Mr3Hunna · **on:** Jul 19, 2018

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 · **Reply #1 on:** Jul 19, 2018

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.