Question

an adult female client who has been taking antipsychotic neuroleptic medication for the past three days has a decrease in psychotic behavior and appears to be responding well to the medication. on the fourth day, the clients blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. which action should the nurse initiate?

place the client on seizure precautions and monitor carefully.
immediately transfer the client to the intensive care unit.
describe the symptoms to the charge nurse and record them on the clients chart.
no action is required at this time as these are known side effects of such drugs.

Explanation:

Identify the clinical presentation and underlying condition

The client is taking an antipsychotic (neuroleptic) medication and presents with increased blood pressure (autonomic instability), pallor, fever (febrile), and muscular rigidity. These symptoms are classic indicators of Neuroleptic Malignant Syndrome (NMS), a rare, life-threatening reaction to neuroleptic medications.

Determine the immediate nursing action

NMS is a medical emergency that requires immediate medical intervention, discontinuation of the neuroleptic agent, and supportive care, typically managed in an intensive care unit (ICU). Therefore, the nurse must immediately transfer the client to the intensive care unit.

Evaluate the incorrect options

• Seizure precautions are important but do not address the primary life-threatening systemic crisis of NMS.
• Reporting to the charge nurse and documenting is insufficient for an acute, life-threatening emergency.
• NMS is not a benign, expected side effect that requires no action; it is a critical adverse reaction.

Answer:

• Place the client on seizure precautions and monitor carefully.
• Immediately transfer the client to the intensive care unit. (Correct answer)
• Describe the symptoms to the charge nurse and record them on the client's chart.
• No action is required at this time as these are known side effects of such drugs.