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Medication administration record
Allergies: None
Medications Time
Haloperidol: 5 mg PO, twice a day 0900, 2100
Hydrochlorothiazide: 25 mg PO, daily 0900
Omeprazole: 20 mg PO, daily 0900
Acetaminophen: 650 mg PO, PRN Every 6 hours
The nurse on the inpatient psychiatric unit is preparing to administer 9 AM medications to a client. On assessment, the client is exhibiting signs of neuroleptic malignant syndrome. Which of the following actions should the nurse take?
- A. Administer acetaminophen, hold the haloperidol and reassess in 30 minutes
- B. Administer all medications, including acetaminophen, and reassess in 30 minutes
- C. Hold the haloperidol and notify the health care provider (HCP) immediately
- D. Hold the hydroxyzine and notify the HCP immediately
Correct Answer: C
Rationale: Neuroleptic malignant syndrome is a life-threatening reaction to antipsychotics like haloperidol, requiring immediate cessation and provider notification. Acetaminophen, continuing medications, or holding hydroxyzine do not address the emergency.
You may also like to solve these questions
The nurse is caring for a client with a fiberglass cast applied to a distal fracture of the right tibia. The client should be able to bear weight on the cast within:
- A. 10 minutes
- B. 30 minutes
- C. 3 hours
- D. 24 hours
Correct Answer: D
Rationale: Fiberglass casts typically require 24 hours to fully dry and harden before weight-bearing. Choices A, B, and C are too short for the cast to achieve sufficient strength.
A 3 year-old child is treated in the emergency department after ingestion of 1 ounce of a liquid narcotic. What action should the nurse perform first?
- A. Provide the ordered humidified oxygen via mask
- B. Suction the mouth and the nose
- C. Check the mouth and radial pulse
- D. Start the ordered intravenous fluids
Correct Answer: C
Rationale: Check the mouth and radial pulse. Assessing airway, breathing, and circulation is the first step in treating toxic ingestion to stabilize the client.
A client asks the nurse about including her 2 and 12 year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?
- A. Focus on your sons' needs during the first days at home.
- B. Tell each child what he can do to help with the baby.
- C. Suggest that your husband spend more time with the boys.
- D. Ask the children what they would like to do for the newborn.
Correct Answer: A
Rationale: In an expanded family, it is important for parents to reassure older children that they are loved and as important as the newborn.
During report, the nurse is given all of the following information. Which client should the nurse go to first?
- A. A diabetic has a blood sugar of 200.
- B. A client who had abdominal surgery earlier today is complaining of operative site pain.
- C. A client who had abdominal surgery yesterday has crackles on auscultation.
- D. A client who had a thyroidectomy earlier today is complaining of muscle spasms.
Correct Answer: D
Rationale: Muscle spasms post-thyroidectomy suggest hypocalcemia from parathyroid injury, a potentially life-threatening emergency requiring immediate assessment. High glucose, pain, or crackles are less urgent.
The nurse is screening clients for those at risk for developing endometrial cancer. Which of the following clients is at highest risk for developing endometrial cancer?
- A. 42-year-old client who has been taking a progestin-containing oral contraceptive for 10 years
- B. 45-year-old client who has a history of one ectopic pregnancy and two births
- C. 51-year-old client who has polycystic ovary syndrome and is obese
- D. 54-year-old client who has a history of hysterectomy for uterine fibroids
Correct Answer: C
Rationale: Obesity and polycystic ovary syndrome (PCOS) increase endometrial cancer risk due to excess estrogen from adipose tissue and anovulation. Ectopic pregnancy and births are not significant risk factors.