Question

The nurse working on the inpatient psychiatric unit is preparing to administer 9:00AM medications to a client. The medication administration record is shown in the exhibit. On assessment, the client is tremulous, exhibits muscle rigidity, and has a temperature of 101.1 F (38.4 C). Which action should the nurse take?

Answer 1

The nurse should withhold the medication and immediately report the signs of tremulousness, muscle rigidity, and fever, as they may indicate Neuroleptic Malignant Syndrome, which requires urgent medical evaluation.

Step-by-step explanation:

The nurse on the inpatient psychiatric unit preparing to administer 9:00AM medications encounters a client who is tremulous, presents muscle rigidity, and has a temperature of 101.1 F (38.4 C). These symptoms are concerning and could be indicative of a serious adverse reaction known as Neuroleptic Malignant Syndrome (NMS), which is often associated with the administration of neuroleptic or antipsychotic medications. It is crucial for the nurse to recognize these signs promptly as NMS can be life-threatening.

The appropriate action for the nurse to take in this situation is to withhold the medication and immediately report the findings to the healthcare provider. Further intervention, such as cooling measures and hydration, may be necessary and an immediate medical evaluation is critical to ensure patient safety and proper treatment. This is consistent with the nursing responsibility to always assess the condition of the patient before administering any medication and to intervene appropriately should potential adverse reactions be identified.