Stage 4 — Generate solutions. The client has been transferred to intensive care and haloperidol has been discontinued. Current data: temperature 40.2 C, HR 132/min, BP fluctuating from 88/50 to 176/102 mm Hg, generalized lead-pipe rigidity, opens eyes to loud voice, gag reflex present, no clonus. Potassium 5.6 mEq/L, creatine kinase 6,800 U/L, creatinine 1.7 mg/dL, dark urine 20 mL/hr. Which actions should the nurse anticipate in the immediate plan? Select all that apply.

Quick answer
Anticipate IV lorazepam with airway monitoring, external cooling with continuous core temperature, and isotonic fluid titrated to urine output (1, 4, 5).

Why this is correct
NMS treatment is removal of the dopamine antagonist plus aggressive supportive care. Lorazepam is first-line pharmacologic therapy for rigidity and agitation in NMS; because the client opens eyes only to a loud voice, the airway and respiratory rate must be watched, but a preserved gag reflex makes a prescribed dose reasonable. Antipyretics do little for centrally driven hyperthermia, so external cooling is required. CK 6,800 U/L with dark urine and rising creatinine means rhabdomyolysis, so isotonic fluid is titrated to urine output to protect the kidneys and help lower potassium.

Easy analogy or mental picture
Picture NMS as a locked brake pedal on dopamine: you release the brake (stop the drug), cool the overheated engine, and flush the debris out of the kidneys while the system resets.

Memory hook
NMS: Stop, Sedate with a benzodiazepine, Soak (cool), and Saline.

NCLEX decision rule
When an antipsychotic reaction is identified, match the treatment to the syndrome: EPS gets anticholinergics, serotonin syndrome gets cyproheptadine, and NMS gets drug withdrawal, benzodiazepines, cooling, and fluids.

Why the other choices are wrong
Benztropine is tempting because it relieves antipsychotic-induced dystonia and rigidity of EPS, but anticholinergics reduce sweating and heat loss and do not treat NMS. Substituting olanzapine seems reasonable because psychosis persists and second-generation agents carry lower risk, but any antipsychotic during active NMS continues dopamine blockade and can worsen it. Cyproheptadine is tempting because hyperthermia with rigidity also occurs in serotonin syndrome, but this client has no serotonergic exposure and no clonus.