The NCLEX-PN question bank.

Answer

The key, and why

Haloperidol decanoate is a long-acting (depot) form of haloperidol. The drug is dissolved in sesame oil and sits in the muscle as a small pool, releasing haloperidol slowly over about 4 weeks. That is what makes it useful for a client who struggles to take tablets every day, and it is also why the injection technique matters so much. If the oil seeps back up the needle track into the fat and skin, the client gets a painful, hard lump at the site and loses part of the dose. The Z-track method stops that leak. Pulling the skin and fat to one side before the needle goes in means the hole in the skin and the hole in the muscle no longer line up once the skin is let go. The track becomes a zigzag, the Z, and the tissue slides over and seals the muscle opening. The picture shows the skin pulled aside and the needle already in the muscle. Next the medication goes in slowly, about 10 seconds for each mL, because oil is thick and a fast push forces it back along the track and hurts. Then the nurse waits 10 seconds with the needle in place so the oil can spread into the muscle. Then the needle comes out smoothly along the same line. Only after the needle is out is the skin let go, so the tissue closes over the track. Afterward the nurse presses lightly with dry gauze and does not massage the site, because rubbing pushes the oil back toward the surface. Sites are rotated, with no more than 3 mL in one site.

Each distractor

Letting go of the skin before withdrawing the needle is the most common error. The skin springs back while the needle is still in, the holes line up again, and the track is open when the needle leaves. Withdrawing the needle straight after the plunger is down skips the 10-second wait, so oil still sitting at the needle tip follows it out. Pushing the plunger quickly forces a thick oil into the muscle under pressure, which causes pain and drives the drug back up the track.

The teaching point

Z-TRACK order → pull skin aside → insert → inject SLOWLY → WAIT 10 seconds → WITHDRAW → RELEASE skin. Needle OUT before skin RELEASED. No massage afterward. Light pressure only. Oily depot = large, deep muscle, no more than 3 mL per site.

Answer

The key, and why

A client with pemphigus vulgaris has large areas of open skin and takes drugs that suppress the immune system, so infection can spread quickly to the bloodstream. Overwhelming infection is the leading cause of death in this disease. Fever with a new change in mental status suggests sepsis. The nurse checks this client first, collects a full set of vital signs and reports to the registered nurse (RN) right away so that blood cultures and early antibiotics can begin. This client is at the greatest risk of rapid decline.

Each distractor

Option A is expected in pemphigus vulgaris, where minor friction such as a tourniquet separates the skin. The blister needs a nonadherent dressing and a report, but it is a local problem in a stable client. Option B needs prompt pain relief and oral care, and the client's intake is watched, but severe mouth pain is expected with oral lesions and is not life-threatening. Option D is high and needs follow-up and possibly insulin, but it is a common effect of prednisone and is not as immediately dangerous as possible sepsis.

The teaching point

PEMPHIGUS + FEVER + NEW CONFUSION = possible SEPSIS. See this client FIRST and REPORT. INFECTION is the leading cause of DEATH in pemphigus vulgaris. NEW BLISTERS from friction are EXPECTED in pemphigus vulgaris.

Answer

The key, and why

Serotonin syndrome is a build-up of serotonin in the nervous system, almost always from two serotonin drugs taken together or a dose increase of one. Sertraline, a selective serotonin reuptake inhibitor, keeps serotonin in the space between nerve cells. Tramadol is a pain reliever that also blocks serotonin reuptake. Starting tramadol 2 days ago on top of a year of sertraline is the classic timing, because serotonin syndrome usually starts within hours to a day or two of the change. The findings fall into three groups, and this client has all three. The mind is restless, agitated and talkative. The autonomic nervous system is racing, with fever, a fast heart rate, heavy sweating, shivering and diarrhea. The muscles are overactive, and the jerking of the foot when the ankle is flexed is clonus, the finding that points most strongly to serotonin syndrome. The two actions stop more serotonin going in and get treatment moving. The next doses of both drugs are held, and the provider hears the findings immediately, because serotonin syndrome can progress to very high fever, seizures and death. The two parameters are the ones that track how severe it is and whether it is settling. A rising body temperature is the most dangerous sign in serotonin syndrome, and the heart rate shows how hard the autonomic system is being driven.

Each distractor

Giving the next tramadol dose adds more of the drug that triggered the reaction. Starting an intravenous infusion of 0.9% sodium chloride is the right idea, since fluids are part of treatment, but starting intravenous therapy is not within the nurse's scope. The nurse reports and the provider orders it, and the registered nurse or the emergency department starts it. A cool shower at home and a recheck tomorrow sends a client with a fever, a racing heart and clonus away from care while the condition may be getting worse. Neuroleptic malignant syndrome follows an antipsychotic, comes on over days and brings stiff, lead-pipe rigid muscles with slowed movement. This client takes no antipsychotic and has jerking, overactive muscles instead. Alcohol withdrawal causes tremor, sweating and a fast heart rate, but there is no history of drinking here, and clonus is not its typical finding. A new serotonin drug is the better explanation. Anticholinergic toxicity makes a person hot but dry, with flushed dry skin, a dry mouth and slowed bowels. This client is sweating heavily and has diarrhea, the opposite. A serum lithium level is monitored for lithium, which this client does not take. The international normalized ratio is monitored for warfarin. It says nothing about serotonin syndrome. Daily weight is part of metabolic monitoring for antipsychotics and fluid monitoring in heart failure. It does not show whether this reaction is getting better or worse.

The teaching point

SEROTONIN SYNDROME = two serotonin drugs together, onset within HOURS. Three groups → MIND (agitation) + AUTONOMIC (fever, fast heart, sweating, diarrhea) + MUSCLES (clonus, brisk reflexes). CLONUS points to serotonin syndrome. LEAD-PIPE rigidity points to neuroleptic malignant syndrome. Sweating + diarrhea = serotonin. Hot + DRY = anticholinergic. Nurse → HOLD both drugs + REPORT immediately. Monitor TEMPERATURE and HEART RATE.