# A nurse is caring for a patient who has developed neuroleptic malignant syndrome (NMS) after starting haloperidol therapy. Which nursing intervention should be the immediate priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=319591 > 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 immediate priority? ## 보기 1. Discontinue the haloperidol and initiate cooling measures **✔ 정답** 2. Administer acetaminophen for fever reduction 3. Increase fluid intake to prevent dehydration 4. Monitor vital signs every 4 hours **정답: 1** ## 해설 NMS is a life-threatening emergency requiring immediate discontinuation of the causative antipsychotic medication and aggressive supportive care including cooling measures. Other options are less urgent or supportive. ## 심화 해설 Core Nursing Explanation **Key Concept Analysis**: This question tests the priority nursing intervention for a life-threatening adverse reaction to antipsychotic medication: Neuroleptic Malignant Syndrome (NMS). NMS is a rare but severe condition characterized by hyperthermia (high fever), muscle rigidity, altered mental status, and autonomic instability (e.g., tachycardia, labile blood pressure). The pathophysiology involves a sudden, profound blockade of dopamine receptors in the hypothalamus and basal ganglia, leading to dysregulation of temperature, muscle tone, and autonomic function. The immediate priority is to stop the causative agent and manage the hyperthermia to prevent permanent neurological damage, rhabdomyolysis, and death. **Answer Rationale**: Key Point! The correct answer is to Discontinue the haloperidol and initiate cooling measures. This is the first and most critical step. Removing the offending drug stops the pathophysiological process. Simultaneously, aggressive cooling (e.g., cooling blankets, ice packs, fans) is essential to lower the dangerously high body temperature, which is the most immediate threat to life and organ function. **Distractor Analysis**: • Watch out for confusion! Option ②, "Administer acetaminophen for fever reduction," is incorrect because the fever in NMS is not caused by the typical hypothalamic prostaglandin-mediated mechanism that antipyretics like acetaminophen target. It is due to central dysregulation and severe muscle rigidity generating heat. Antipyretics are ineffective, and using them delays critical cooling interventions. • Option ③, "Increase fluid intake to prevent dehydration," is an important **supportive** measure due to hyperthermia and diaphoresis, but it is not the *immediate priority*. IV fluids are typically administered, but the first actions must address the root cause (drug) and the primary life threat (hyperthermia). • Option ④, "Monitor vital signs every 4 hours," is grossly inadequate for a patient in a medical emergency. A patient with NMS requires **continuous or very frequent** monitoring (e.g., every 15-30 minutes initially) of vital signs, neurological status, and lab values (like CK for rhabdomyolysis). This option represents a routine, non-urgent level of care. **Related Concepts**: NMS must be differentiated from Watch out for confusion! Serotonin Syndrome, another life-threatening drug reaction. While both involve altered mental status, autonomic dysfunction, and hyperthermia, Serotonin Syndrome features **hyperreflexia, clonus, and agitation**, whereas NMS is characterized by **"lead-pipe" muscle rigidity and bradykinesia**. Malignant hyperthermia (MH), a reaction to volatile anesthetics and succinylcholine, is another key differential diagnosis. Concept Summary • **Neuroleptic Malignant Syndrome (NMS)**: Life-threatening reaction to antipsychotics (typical > atypical). • **Classic Tetrad**: Fever, Muscle Rigidity, Altered Mental Status, Autonomic Instability. • **Pathophysiology**: Sudden, profound central dopamine D2 receptor blockade. • **Immediate Priorities**: 1. Stop the antipsychotic. 2. Cool the patient aggressively. 3. Provide supportive care (IV fluids, monitor for complications). • **Pharmacological Treatment**: Dopamine agonists (e.g., bromocriptine) and muscle relaxants (e.g., dantrolene) may be used. Side-by-Side Comparison! | Feature | Neuroleptic Malignant Syndrome (NMS) | Serotonin Syndrome | | --- | --- | --- | | Primary Cause | Dopamine receptor blockade (Antipsychotics) | Excess serotonin activity (SSRIs, SNRIs, MAOIs) | | Onset | Days to weeks after starting/changing dose | Hours to days after starting/changing dose | | Key Neuromuscular Sign | "Lead-pipe" rigidity, Bradykinesia | Hyperreflexia, Inducible clonus, Myoclonus | | Mental Status | Stupor, Catatonia | Agitation, Confusion, Anxiety | | First-Line Treatment | Stop antipsychotic, Cooling, Supportive care | Stop serotonergic drug, Cyproheptadine (antidote), Supportive care | Anatomy, Physiology & Pharmacology Points • **Hypothalamus**: The body's thermostat. Dopamine blockade here disrupts temperature regulation. • **Basal Ganglia Responsible for motor control. Dopamine blockade here causes severe rigidity. • Dopamine (D2) Receptors**: The primary target of typical antipsychotics like haloperidol. Their blockade is the trigger for NMS. • **Creatine Kinase (CK)**: A lab value that will be severely elevated (>1000 U/L, often >10,000) due to muscle breakdown (rhabdomyolysis) from rigidity. Memory Tips • **Acronym for NMS Signs: FEVER** F - Fever (High) E - Encephalopathy (Altered mental status) V - Vital sign instability (Autonomic) E - Elevated enzymes (CK, WBC) R - Rigidity (Muscle) • **Priority Mnemonic**: "**S**top the **D**rug, **C**ool the **P**atient" (SDCP). High-Frequency NCLEX Topics The NCLEX loves to test **priority-setting** in emergency situations. NMS is a classic example where you must identify the *most immediate, life-preserving action* before moving to supportive measures. Expect questions that ask for the "first," "immediate," or "priority" nursing action. Knowing the difference between NMS and Serotonin Syndrome is also a high-yield topic. Watch Out for Question Variations! • Instead of asking for the intervention, a question might ask: "**Which finding is most indicative of NMS?**" (Answer: Hyperthermia with severe muscle rigidity). • It could present a lab value: "**The nurse reviews the patient's lab results. Which finding supports the diagnosis of NMS?**" (Answer: Markedly elevated Creatine Kinase (CK)). • It could test differential diagnosis: "**A patient on fluoxetine is agitated, diaphoretic, and has clonus. The nurse suspects...**" (Answer: Serotonin Syndrome, not NMS). ## 임상 시나리오 Nursing Clinical Practice Guide **Clinical Scenario**: You are the nurse on a medical-psychiatric unit. Mr. Johnson, a 65-year-old patient with schizophrenia, was started on haloperidol 5mg PO BID three days ago. During your morning assessment, you find him diaphoretic, minimally responsive to voice, and with notably stiff arms. His vital signs are: Temp 40.1°C (104.2°F), HR 128, BP 168/94. You immediately recognize the possibility of NMS. **Nursing Intervention Strategy**: 1. **Immediate Action (ABCs & Priority)**: Call a rapid response or code team. While awaiting the team, **discontinue the haloperidol immediately** (document "HOLD - Suspected NMS"). Initiate **aggressive cooling**: remove blankets, apply ice packs to groin/axillae/neck, use a fan, and consider a cooling blanket per protocol. Administer high-flow oxygen. 2. **Assessment & Monitoring**: Obtain stat labs: CK, electrolytes, renal function, CBC. Insert a Foley catheter to monitor urine output (watch for dark urine indicating myoglobinuria from rhabdomyolysis). Monitor vital signs and neurological status **continuously or every 15 minutes** initially. 3. **Collaborative Care**: The physician will likely order IV fluids for hydration and renal protection, medications like **dantrolene** (for muscle rigidity) and **bromocriptine** (a dopamine agonist). Prepare for possible transfer to ICU. 4. **Patient Safety and Precautions**: Handle the patient gently due to rigidity. Maintain a quiet environment. Be prepared for seizures or cardiac arrhythmias. **Never** restart the causative antipsychotic. Future antipsychotic use requires extreme caution and close monitoring. Nursing Procedure & Medication Flow • **Cooling Procedure**: Goal is to reduce core temperature to ## 핵심 개념 - **Neuroleptic Malignant Syndrome** — A life-threatening reaction to antipsychotic drugs characterized by hyperthermia, severe muscle rigidity, altered mental status, and autonomic dysfunction. - **Dopamine Receptor Blockade** — The primary pathophysiological mechanism of NMS, where antipsychotic drugs block dopamine D2 receptors in the hypothalamus and basal ganglia. - **Rhabdomyolysis** — Breakdown of skeletal muscle tissue, releasing myoglobin into the bloodstream, which can cause acute kidney injury. A common and dangerous complication of NMS due to severe muscle rigidity. - **Dantrolene** — A direct-acting skeletal muscle relaxant used in the treatment of NMS to reduce severe muscle rigidity and associated heat production. - **Serotonin Syndrome** — A potentially life-threatening condition caused by excessive serotonergic activity, often confused with NMS. Key features include agitation, hyperreflexia, clonus, and hyperthermia. ## 같은 주제 문제 - [A nurse is caring for a patient who has been receiving haloperidol for schizophrenia. The …](https://mymerci.kr/pages/nclex_q.php?qn_id=319588) - [A nurse is caring for a patient who has been receiving olanzapine for schizophrenia. 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