# 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.

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> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## Question

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.

1

Infuse prescribed isotonic fluid titrated to hourly urine output

2

Ask the prescriber to substitute olanzapine for the held haloperidol

3

Request cyproheptadine by nasogastric tube to reduce the rigidity

4

Give prescribed IV lorazepam and monitor airway and respirations

5

Apply external cooling and track core temperature continuously

6

Give prescribed IM benztropine to relieve the generalized rigidity

## Explanation

Benzodiazepines (with airway monitoring because arousal is reduced), external cooling, and isotonic fluid titrated to urine output are the core supportive measures for NMS with rhabdomyolysis. Benztropine treats extrapyramidal dystonia but its anticholinergic effect impairs heat loss and does not treat NMS; switching to olanzapine re-exposes the client to dopamine blockade; cyproheptadine is the antidote for serotonin syndrome, which the absent clonus argues against.

## In-depth explanation

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.

References
1StatPearls: Neuroleptic Malignant Syndrome (NCBI Bookshelf)NMS management: discontinue antipsychotic, benzodiazepines, cooling, IV fluids for rhabdomyolysis; avoid anticholinergics and rechallenge during the acute episode
2StatPearls: Serotonin Syndrome (NCBI Bookshelf)Cyproheptadine is used for serotonin syndrome, which presents with clonus after serotonergic drugs

## Clinical scenario

Case update
The client is in intensive care with hyperthermia, rigidity, labile blood pressure, hyperkalemia, and myoglobinuria after haloperidol exposure.

## Key concepts

- **Rhabdomyolysis** — Breakdown of skeletal muscle that releases creatine kinase, potassium, and myoglobin and can cause acute kidney injury.
- **Benzodiazepine therapy in NMS** — Use of agents such as lorazepam to reduce rigidity and agitation, requiring monitoring of airway and respirations.
- **Anticholinergic heat retention** — Drugs such as benztropine reduce sweating and can worsen hyperthermia.

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