Question set B: next-generation items on psychotropic emergencies, with condensed rationales
An eight-row by three-column matrix grid with empty checkboxes in every cell, and a separate outlined answer strip beneath showing filled boxes only, printed inverted.
Item 1 MATRIX A patient started on haloperidol four days ago has generalized rigidity, a temperature of 103.1 degrees Fahrenheit, blood pressure swinging between 90/54 and 168/96, and decreased reflexes. Classify each nursing action as Anticipated, Non-essential, or Contraindicated.
| Action | Anticipated | Non-essential | Contraindicated |
|---|---|---|---|
| 1. Stop the haloperidol | ☐ | ☐ | ☐ |
| 2. Begin active cooling measures | ☐ | ☐ | ☐ |
| 3. Give intravenous fluids as ordered | ☐ | ☐ | ☐ |
| 4. Monitor creatine kinase and renal function | ☐ | ☐ | ☐ |
| 5. Give the next scheduled haloperidol dose | ☐ | ☐ | ☐ |
| 6. Prepare to give dantrolene | ☐ | ☐ | ☐ |
| 7. Escort the patient to the scheduled art group | ☐ | ☐ | ☐ |
| 8. Apply physical restraints to control the rigidity | ☐ | ☐ | ☐ |
Item 2 BOW A patient taking sertraline was started on tramadol yesterday. He now has agitation, diarrhea, diaphoresis, dilated pupils, and clonus at both ankles. Select the condition, two actions, and two parameters.
Condition: neuroleptic malignant syndrome | serotonin syndrome | anticholinergic toxicity | alcohol withdrawal Actions: stop all serotonergic agents | increase the sertraline dose | give a benzodiazepine as ordered | apply warming blankets | restrict oral fluids Parameters: temperature | deep tendon reflexes and clonus | pupil size at every meal | hair growth | bowel habits weekly
Item 3 DDT Complete the sentence.
A patient taking lithium has vomited for two days and her creatinine has risen on each of the past three days. The vomiting has produced [drop-down 1], which [drop-down 2] the lithium level.
Drop-down 1: volume loss with sodium depletion | potassium excess | hepatic enzyme induction | increased renal clearance Drop-down 2: raises | lowers | does not change | has no measurable effect on
Item 4 TREND A patient in alcohol withdrawal is monitored across twelve hours. At which point does the nurse escalate?
1800 HR 96 BP 138/84 Temp 98.8 F Mild hand tremor, oriented, anxious 2200 HR 108 BP 146/88 Temp 99.2 F Tremor increased, oriented, restless 0200 HR 122 BP 158/94 Temp 100.6 F Gross tremor, diaphoretic, "bugs on the wall," oriented to person only 0600 HR 130 BP 164/98 Temp 101.2 F Disoriented, agitated, pulling at lines
- 1800 2. 2200 3. 0200 4. 0600
CONDENSED RATIONALES
Item 1 — Answer: Anticipated 1, 2, 3, 4, 6 / Non-essential 7 / Contraindicated 5, 8 Lead-pipe rigidity with hyporeflexia four days into an antipsychotic is neuroleptic malignant syndrome. Stopping the drug precedes cooling. Group activity is non-essential. Another dose worsens it, and restraints add heat, muscle work, and rhabdomyolysis risk.
Item 2 — Answer: serotonin syndrome; stop all serotonergic agents and give a benzodiazepine as ordered; monitor temperature and deep tendon reflexes with clonus Clonus is the serotonin discriminator. Increasing sertraline worsens it, warming blankets are the opposite of the treatment, and fluid restriction has no role.
Item 3 — Answer: volume loss with sodium depletion; raises Sodium and lithium are handled together by the kidney. When volume and sodium fall, lithium is retained and the level climbs.
Item 4 — Answer: 3 Escalate at 0200. The transition from tremor and anxiety to perceptual disturbance with fever and disorientation marks the move toward delirium tremens. Waiting for 0600 waits for the emergency itself.
Scoring line: four of four in under six minutes is exam-ready. Three or fewer sends you to page 6 and page 8.
Watch outin neuroleptic malignant syndrome, stop the drug before you cool the patient. Margin note: NGN pays for precision, not speed alone.
Takeawayevery psychotropic emergency item is decided by one discriminating cue, and naming that cue is faster than reasoning through the whole stem.