The nurse is caring for a client with major depressive disorder who was recently placed on a high-potency neuroleptic (antipsychotic) medication. The client has not been eating well, is starting to get dehydrated, and has a temperature of 101°F
The physician orders antibiotics. Six hours later, the nurse notice that the client's temperature has risen to 103°F, and the client has muscle rigidity, and a fluctuating blood pressure. The priority of action for the nurse is to: 1. Discontinue neuroleptic and report symptoms to physician immediately.
2. Chart the assessment findings and report them to the primary nurse at change of shift.
3. Discontinue the neuroleptic and document assessment findings as cause for the action.
4. Continue the medications and perform more frequent assessments of the client.
1
Rationale: These symptoms are indicative of neuroleptic malignant syndrome, a potentially fatal idiopathic response to high-potency neuroleptic medications. The medication should be discontinued, and the physician notified immediately.
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