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When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client's record should the nurse review?
- A. The healthcare provider's history and physical.
- B. Recent urine drug testing (UDT) results.
- C. Baseline nursing admission assessment.
- D. Abnormal Involuntary Movement Scale (AIMS).
Correct Answer: D
Rationale: The Abnormal Involuntary Movement Scale (AIMS) is specifically designed to assess and document involuntary movements associated with psychotropic medications, making it the most relevant assessment tool for these symptoms.
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While visiting the community mental health center, a client with a diagnosis of major depressive disorder asks the nurse if what is shared with the staff will be shared with family members. How should the nurse respond to this client?
- A. Provide the client with a written hospital policy regarding privacy of information laws.
- B. Tell the client that confidentiality will be maintained, except when one's safety is threatened.
- C. Nod in the affirmative, but make no verbal commitment to the client.
- D. Assure the client that information provided will be shared with the staff only.
Correct Answer: B
Rationale: This response provides accurate information about confidentiality while acknowledging exceptions when safety is at risk, addressing the client's concern clearly.
A client diagnosed with schizophrenia has been receiving haloperidol for the past year, and the treatment plan includes moving the client to a lower maintenance dosage. Which intervention should the nurse include in this client's plan of care? (Select all that apply)
- A. Shielding the client from direct sunlight when outdoors.
- B. Gradually withdrawing the medication over several days.
- C. Enforcing a fluid restriction during dosage adjustment.
- D. Increasing the dosage if the white blood cell count drops.
Correct Answer: A,B
Rationale: Shielding from sunlight prevents sunburn due to haloperidol's photosensitivity, and gradual withdrawal avoids symptom worsening.
A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?
- A. Administer disulfiram immediately.
- B. Place in a side-lying position with the head of the bed elevated.
- C. Give lorazepam PRN for signs of withdrawal.
- D. Provide thiamine and folate supplements as prescribed.
Correct Answer: B
Rationale: Placing the client in a side-lying position with the head elevated prevents aspiration and maintains airway patency, critical for a client with altered consciousness.
An adolescent male who was arrested a month ago for gang-related activities has a court order to attend weekly group therapy sessions at the mental health clinic. Today his mother calls the clinic nurse to report that her son became angry last night and put his fist through a window. Which intervention is most important for the nurse to implement?
- A. Advise the mother to call the police if violent behavior occurs again.
- B. Refer the mother for psychiatric evaluation for anxiety and depression.
- C. Reinforce the need for the adolescent to attend group therapy sessions.
- D. Tell the mother to describe her feelings of helplessness to her son.
Correct Answer: A
Rationale: Advising the mother to call the police if violent behavior occurs again addresses the safety of the client and others, ensuring appropriate intervention.
The nurse assesses a client who recently began experiencing violent nightmares. Which factor in the client's history should the nurse further explore?
- A. Family history of dementia.
- B. Witness to an accident.
- C. Alcohol use.
- D. Inadequate diversional activity.
Correct Answer: C
Rationale: Alcohol use can contribute to sleep disturbances, including nightmares, making it a critical factor to explore in relation to the client's symptoms.