hard · NCLEX-RN psychosocial
The nurse reviews the client's record at 12:00. Which findings are relevant to the immediate change in the client's condition? Select all that apply. Apply the response specifically to this case: client taking antipsychotic medication who develops fever, lead-pipe rigidity, autonomic instability, and escalating confusion while staff initially attribute behavior to personality disorder.
- Core body temperature of 40.2 C (104.4 F)
- Generalized 'lead-pipe' muscle rigidity in all four extremities
- Refusal to eat breakfast and delusional belief about poisoned food
- Heart rate of 134/min and blood pressure of 178/104 mm Hg
- Stuporous mental state and inability to follow commands
- History of paranoid schizophrenia and borderline personality disorder
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