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?
Mostly cloudy
Constipation
Dry mouth
Daytime drowsiness
Muscle stiffness
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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Correct Answer is C
Explanation
Rationale:
A. Applying a warming blanket is not appropriate and may worsen the client’s reaction to the infusion. It does not help prevent infusion-related reactions.
B. Infusing amphotericin B deoxycholate over 1 hour is too fast; the medication should be infused over 2-6 hours to reduce the risk of adverse effects.
C. Administering diphenhydramine prior to administration is recommended to help prevent infusion-related reactions, such as fever and chills, which the client experienced during previous infusions.
D. Monitoring vital signs once per hour is inadequate; vital signs should be monitored more frequently during and immediately after the infusion to promptly identify and manage any adverse reactions.
Correct Answer is D
Explanation
Rationale:
A. Mostly cloudy: This option appears to be incorrectly stated. It does not pertain to a critical client assessment related to morphine administration.
B. Apical heart rate: Monitoring the heart rate is important, but respiratory depression is a more immediate and life-threatening concern with morphine administration, so it is not the first priority.
C. Blood pressure: Morphine can cause hypotension, but this is not as critical as respiratory depression, which must be assessed first in opioid administration.
D. Respiratory rate: The most critical assessment when administering morphine is the respiratory rate, as opioid medications like morphine can cause respiratory depression, which can be life-threatening if not addressed.
E. Level of consciousness: While important, changes in consciousness typically follow respiratory depression, so assessing the respiratory rate takes priority.