A 70yearold client is admitted to the locked psychiatric unit, diagnosed with delirium. Later in the day, he tries to get out of the locked unit several times. He yells, "I have to leave and get to my barber. I see him every Wednesday. Let me out!"

Which of the following would be the most therapeutic response by the nurse?

"You need to come and take a shower before you can go get your hair cut."

"Please stop banging on the door. Your room is right over there."

"The door is locked so that you don't leave and get hurt."

"You are in the hospital, and I'm your nurse."

Answer and Explanation

The Correct Answer is C

A.   This response does not directly address the client's concern and may be perceived as dismissive.
B.   This response does not provide a clear explanation for the locked door and may not effectively address the client's agitation.
C.   This response provides a clear and honest explanation for the locked door, ensuring the client's safety, which is the priority.
D.   This response acknowledges the situation but does not provide a clear explanation for the locked door.

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Correct Answer is B

Explanation

A) Incorrect. While understanding if the client is experiencing a relapse is important, knowing the timing of the last drink is crucial for assessing the level of intoxication.

B) Correct. Knowing the time of the last drink helps the nurse gauge the current level of alcohol in the client's system, which is crucial in assessing and managing alcohol intoxication.

C) Incorrect. While understanding the duration of the client's problem with alcohol is important, it is not the most immediate concern when the client is showing symptoms of intoxication.

D) Incorrect. Asking about liver problems is relevant but not the first priority when the client is exhibiting signs of alcohol intoxication.

A. Clients who have received long-term neuroleptic treatment. B. Clients who have discontinued their neuroleptic treatment. C. Clients who have experienced neuroleptic malignant syndrome (NMS). D. Clients who have received monoamine oxidase inhibitors (MAOIS).

Correct Answer is A

Explanation

A) Correct. Tardive dyskinesia is a side effect of long-term neuroleptic (antipsychotic) treatment. It is characterized by involuntary, repetitive movements, particularly of the face and tongue. This condition is more commonly seen in clients who have been on neuroleptics for extended periods.

B) Incorrect. Discontinuing neuroleptic treatment may lead to withdrawal symptoms or symptom recurrence, but it does not directly increase the risk of developing tardive dyskinesia.

C) Incorrect. Neuroleptic malignant syndrome (NMS) is a different side effect associated with neuroleptic medications, characterized by hyperthermia, autonomic dysregulation, altered mental status, and generalized muscle rigidity.

D) Incorrect. Monoamine oxidase inhibitors (MAOIs) are a different class of medications and are not associated with the development of tardive dyskinesia.

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Naxlex Comprehensive Predictor Exams

A client is showing symptoms of alcohol intoxication. What question should the nurse ask first?

Correct Answer is B

Explanation

What client population is at risk of developing tardive dyskinesia?

Correct Answer is A

Explanation

A nurse in the emergency department is implementing a plan of care for an older adult client who is experiencing delirium tremens. Which of the following actions should the nurse take first?

A client with schizophrenia has begun a new prescription of clozapine. The nurse should assess the result of which laboratory study to monitor for adverse effects?

A client diagnosed with schizophrenia is experiencing delusions of persecution. How would the client express feeling persecuted?

The nurse states in report that the client is experiencing positive symptoms of schizophrenia. What symptoms would the nurse receiving report expect to observe?

Which statement made by the nurse would be most appropriate to an elderly client who is confused, has no history of dementia and is hospitalized for an acute urinary tract infection?

The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse would monitor for which symptoms?

A client diagnosed with bipolar II disorder has a problem statement of impaired social interactions related to egocentrism. Which short-term correctly written outcome is an appropriate expectation for this client problem?