# A nurse is caring for a patient who has developed neuroleptic malignant syndrome (NMS) after starting haloperidol therapy. Which nursing intervention should be the highest priority?

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=319590  
> language: ko  
> subject: Pharmacology

## 문제

A nurse is caring for a patient who has developed neuroleptic malignant syndrome (NMS) after starting haloperidol therapy. Which nursing intervention should be the highest priority?

## 보기

1. Administer acetaminophen for fever reduction
2. Apply cooling blankets to reduce body temperature
3. Monitor vital signs every 15 minutes
4. Discontinue the antipsychotic medication immediately **✔ 정답**

**정답: 4**

## 해설

Immediate discontinuation of the antipsychotic is the highest priority to halt progression of neuroleptic malignant syndrome (NMS), a life-threatening emergency. Other interventions like fever reduction or monitoring are supportive but secondary.

## 심화 해설

Core Nursing Explanation
**Key Concept Analysis**: This question tests the priority nursing intervention for Neuroleptic Malignant Syndrome (NMS), a rare but life-threatening reaction to antipsychotic medications (e.g., haloperidol). The core pathophysiology involves a dysregulation of dopamine in the hypothalamus, leading to severe muscle rigidity, hyperthermia, autonomic instability, and altered mental status. The priority is always to remove the causative agent to stop the progression of the syndrome.

**Answer Rationale**: Key Point! The single most critical and immediate action in NMS is to discontinue the offending antipsychotic medication. This is the definitive treatment that addresses the root cause. All other interventions are supportive measures that manage symptoms but do not stop the underlying pathological process. In the nursing process, this aligns with the principle of first removing the source of harm.

**Distractor Analysis**:

Watch out for confusion! While **Administer acetaminophen for fever reduction (Option 1)** and **Apply cooling blankets to reduce body temperature (Option 2)** are important supportive measures for managing hyperthermia, they are *secondary* to stopping the causative drug. The fever in NMS is central in origin (due to hypothalamic dysregulation) and often does not respond well to standard antipyretics alone.

Watch out for confusion! **Monitor vital signs every 15 minutes (Option 3)** is a crucial nursing action for a patient in a critical condition. However, it is an assessment and monitoring intervention, not a direct treatment. Priority is given to interventions that directly treat the problem over those that monitor it.

**Related Concepts**: NMS is a medical emergency. After discontinuing the medication, supportive care becomes the focus: aggressive cooling, IV hydration, management of rigidity (possibly with dantrolene or benzodiazepines), and monitoring for complications like rhabdomyolysis (checking creatinine kinase (CK) levels) and renal failure. It is often compared and contrasted with Serotonin Syndrome, another drug-related emergency.

## 임상 시나리오

Nursing Clinical Practice Guide
**Clinical Scenario**: You are a nurse on a medical-psychiatric unit. Mr. Johnson, a 65-year-old patient with schizophrenia, was started on haloperidol 48 hours ago. He is now found to be lethargic, has a temperature of 40.1°C (104.2°F), "lead-pipe" rigidity in his arms, a blood pressure of 170/100 mmHg, and is diaphoretic.

**Nursing Intervention Strategy**:
1.  **Immediate Action (Priority)**: Withhold the next scheduled dose of haloperidol and immediately notify the physician/NP to obtain an order to discontinue the medication permanently. Document the time and action taken.
2.  **Supportive Care & Monitoring**:
*   **Temperature Management**: Initiate external cooling measures per protocol (cooling blankets, ice packs to groin/axillae, tepid sponging). Antipyretics like acetaminophen are often given but are less effective alone.
*   **Vital Signs & Neurological Monitoring**: Monitor temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation frequently (e.g., every 15-30 minutes initially). Perform frequent neurological checks using the Glasgow Coma Scale (GCS).
*   **IV Access & Hydration**: Ensure patent IV access for fluid resuscitation to prevent shock and maintain renal perfusion, especially crucial if rhabdomyolysis develops.
*   **Laboratory Monitoring**: Anticipate orders for CK, electrolytes, BUN/Creatinine, and liver function tests. A dramatically elevated CK confirms muscle breakdown.
3.  **Patient Safety and Precautions**:
*   Monitor for signs of aspiration due to dysphagia from rigidity and decreased consciousness. Keep the head of bed elevated if possible and have suction equipment ready.
*   Monitor urine output and color (myoglobinuria can cause dark, tea-colored urine).
*   Provide a calm, quiet environment and gentle range-of-motion exercises cautiously to prevent injury from severe rigidity.

Nursing Procedure & Medication Flow
*   **Medication Administration**: When a drug is identified as the cause of a severe reaction like NMS, the "rights" of medication administration include the **right to refuse** to give a harmful drug. Document clearly: "Haloperidol held d/t suspected NMS, provider notified."
*   **Supportive Medications**: Be prepared to administer medications like dantrolene (a muscle relaxant) or bromocriptine (a dopamine agonist) as ordered. Know their indications and monitor for side effects (e.g., hepatotoxicity with dantrolene).

A Word from Your Senior Nurse
"NMS is a true 'stop-the-line' emergency in psychiatric and medical nursing. Your quick recognition and action to stop the antipsychotic can be life-saving. Remember the classic triad: **Fever, Rigidity, and Altered Mental Status** after starting or increasing an antipsychotic. In the heat of the moment, it's easy to jump to cooling the fever, but always ask yourself first: 'What's causing this?' Removing the cause is almost always the highest priority intervention. This clinical reasoning is exactly what the NCLEX tests."

## 핵심 개념

- **Neuroleptic Malignant Syndrome** — A life-threatening reaction to antipsychotic drugs characterized by fever, severe muscle rigidity, autonomic dysfunction, and altered mental status.
- **Dopamine Antagonist** — A drug that blocks dopamine receptors; typical antipsychotics like haloperidol are potent dopamine antagonists, which can lead to NMS.
- **Rhabdomyolysis** — Breakdown of skeletal muscle tissue releasing myoglobin into the bloodstream, a dangerous complication of NMS that can cause acute kidney injury.
- **Creatine Kinase** — A lab enzyme released from damaged muscle; levels are markedly elevated in NMS due to severe rigidity and rhabdomyolysis.
- **Serotonin Syndrome** — A potentially life-threatening drug reaction caused by excessive serotonergic activity, with symptoms overlapping NMS (agitation, hyperthermia, autonomic changes) but often with hyperreflexia/clonus rather than "lead-pipe" rigidity. Concept Summary * Cause: Antipsychotic (especially typical/high-potency) or sudden withdrawal of dopamine agonists. * Patho: Central dopamine D2 receptor blockade in hypothalamus and basal ganglia. * Symptoms (Classic Triad): Fever, "Lead-pipe" Muscle Rigidity, Altered Mental Status + Autonomic instability (tachycardia, labile BP, diaphoresis). * Priority Intervention: Immediately discontinue the causative antipsychotic medication. * Key Labs: Drastically elevated Creatine Kinase (CK), possible leukocy

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