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A nurse is assessing a client who has a prescription for haloperidol 0.5 mg PO three times daily. The medication administration record shows that the client received 5 mg per dose on the previous day. Which of the following manifestations is the nurse's priority to assess?

A.

Mostly cloudy

B.

Constipation

C.

Dry mouth

D.

Daytime drowsiness

E.

Muscle stiffness

Answer and Explanation

The Correct Answer is E

Rationale: 

 

A. Mostly cloudy: This is an unclear statement. It is not related to a physical manifestation that would result from haloperidol overdose. 

 

B. Constipation: Although haloperidol can cause constipation as a side effect, it is not the most urgent concern. Other manifestations are more immediately life-threatening. 

 

C. Dry mouth: Dry mouth is a common side effect of antipsychotics, but it is not life-threatening and would not be the priority assessment in the case of a medication overdose. 

 

D. Daytime drowsiness: Sedation is a known side effect of haloperidol, but it is not the priority in this scenario where an overdose occurred. 

 

E. Muscle stiffness: Muscle stiffness may indicate extrapyramidal symptoms (EPS) or neuroleptic malignant syndrome (NMS), both of which are serious and potentially life-threatening side effects of haloperidol, especially in cases of overdose. Assessing for these symptoms is the priority.

 


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View Related questions

Correct Answer is A

Explanation

Rationale:

A. Increase calcium intake: Leuprolide can cause a decrease in bone density, increasing the risk of osteoporosis. Therefore, the nurse should advise the client to increase calcium and vitamin D intake to help maintain bone health.

B. Keep the solution cold for administration: Leuprolide should be stored at room temperature, not refrigerated, for subcutaneous administration.

C. This medication can cause low blood glucose levels: Leuprolide does not typically affect blood glucose levels. However, it can cause other endocrine-related side effects, such as hot flashes and reduced libido.

D. This medication can cause constipation: Constipation is not a common side effect of leuprolide. Instead, leuprolide is more likely to cause side effects such as hot flashes and loss of bone density.

Correct Answer is B

Explanation

Rationale:

A. Dyspepsia: While dyspepsia can be uncomfortable, it is not a critical finding that requires immediate reporting to the provider. It may be a common side effect of statins but typically does not warrant urgent intervention.

B. Elevated creatine kinase: An elevated creatine kinase level can indicate muscle damage, which is a serious side effect associated with rosuvastatin and other statins. This finding requires immediate reporting to prevent complications such as rhabdomyolysis.

C. Headache: A headache may occur with many medications and does not usually require immediate reporting unless it is severe or persistent.

D. Mostly cloudy: This option does not pertain to any specific clinical finding or symptom and is therefore not relevant to the question.

E. Decreased HDL cholesterol: While low HDL cholesterol can be a concern, it is not as urgent as elevated creatine kinase levels and typically does not require immediate action.

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