A nurse is caring for a client. Exhibits Complete the following sentence by using the lists of options. Drag words from the choices below to fill in each blank in the following sentence. The nurse identifies the client's dropdownand dropdowncan indicate a life-threatening reaction to the client's scheduled medication.
Explanation & Rationale
Rationale: Heart rate: The client's heart rate has increased to 124 beats per minute, which is significantly higher than normal. This tachycardia could be a sign of neuroleptic malignant syndrome (NMS), a potentially life-threatening reaction to antipsychotic medications like haloperidol. Temperature: The client's elevated temperature of 39.5°C (103.1°F) is concerning and could be indicative of NMS, which often presents with hyperthermia as one of its hallmark symptoms. NMS is a medical emergency that requires immediate attention. Rationale for incorrect choices: Vision report: The client's report of blurry vision may be a side effect of haloperidol, but it is not typically considered a life-threatening reaction. It should be monitored but does not indicate an immediate crisis. Blood pressure: While the blood pressure is slightly low, it is not as critical as the combination of elevated heart rate and temperature. The low blood pressure would require monitoring but is not immediately indicative of a life-threatening reaction. Mouth report: Dry mouth is a common side effect of many medications, including antipsychotics like haloperidol. While uncomfortable, it is not a life-threatening condition. Respiratory rate: The respiratory rate of 22/min is within normal limits and does not indicate any immediate concerns related to the medication. It should be monitored but does not raise a red flag for a life-threatening reaction.