A client on a mental health unit develops flu-like symptoms and low blood pressure. After reviewing the client's history, it was noted that the client has a diagnosis of schizophrenia and is currently taking risperidone (Risperdal). The nurse should recognize that which of the following adverse effects may be occurring?

Neuroleptic malignant syndrome.

Tardive dyskinesia.

Acute dystonia.

Pseudoparkinsonism.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Neuroleptic malignant syndrome (NMS) is a potentially life-threatening condition that can occur as a severe adverse effect of antipsychotic medications, such as risperidone (Risperdal). Symptoms of NMS include flu-like symptoms (fever, muscle rigidity, and sweating) along with altered mental status, and autonomic dysregulation. It's crucial for the nurse to recognize this potentially fatal condition promptly and intervene appropriately.

Choice B rationale:

Tardive dyskinesia is a movement disorder that is often a result of long-term use of antipsychotic medications, but it is characterized by repetitive, involuntary movements of the face and other body parts. It doesn't typically present with flu-like symptoms or low blood pressure.

Choice C rationale:

Acute dystonia is characterized by involuntary muscle contractions and spasms, often involving the muscles of the face, neck, and back. It usually occurs shortly after starting antipsychotic treatment. While it can cause discomfort, it doesn't present with flu-like symptoms and low blood pressure as described in the scenario.

Choice D rationale:

Pseudoparkinsonism, also known as drug-induced parkinsonism, is characterized by symptoms similar to Parkinson's disease, such as tremors, bradykinesia (slowness of movement), and rigidity. It doesn't typically cause flu-like symptoms and low blood pressure.

Nursing Test Bank

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Correct Answer is A

Explanation

The correct answer is choice A: Set limits for the relationship.

Choice A rationale:

Setting limits for the therapeutic relationship (Choice A) is an essential nursing action. Boundaries help create a safe and structured environment, ensuring that both the nurse and client maintain appropriate roles. Limits prevent overstepping boundaries that could compromise the therapeutic alliance.Setting limits for the relationship is an essential part of establishing a therapeutic relationship in a mental health setting. This helps to maintain professional boundaries and ensures that the relationship remains focused on the client’s needs and therapeutic goals.

Choice B rationale:

Engaging in affectionate interactions with the client (Choice B) is not appropriate in a therapeutic relationship. Professionalism and maintaining appropriate boundaries are crucial in psychiatric nursing. Affectionate interactions could blur the lines between the therapeutic relationship and personal relationships, potentially harming the client's progress.

Choice C rationale:

Promoting the use of transference by the client (Choice C) is not a suitable approach. Transference occurs when a client projects feelings and emotions onto the nurse based on past experiences. While it can be valuable to explore transference, actively promoting it could lead to confusion and misunderstandings in the therapeutic relationship.

Choice D rationale:

Instructing the client on how they should behave (Choice D) is contrary to the principles of a therapeutic relationship. The therapeutic relationship is client-centered, where the nurse supports the client's self-discovery and growth. Directing the client's behavior undermines their autonomy and inhibits their progress.

A. "I pray when I begin to breathe fast.” B. "I journal when I find it difficult to talk.” C. "I fix myself a pot of coffee when I get anxious.” D. "I exercise when my neck is tense.”

Correct Answer is C

Explanation

Choice A rationale:

Praying and using relaxation techniques when experiencing rapid breathing are effective stress management strategies. These techniques help manage the body's stress response and promote relaxation.

Choice B rationale:

Journaling is a constructive way to manage stress, especially when verbal expression is difficult. It allows individuals to reflect on their thoughts and emotions, leading to a sense of relief.

Choice C rationale:

"Fixing a pot of coffee" when anxious is the least effective technique mentioned. Consuming large amounts of caffeine can exacerbate anxiety symptoms by increasing heart rate and contributing to a sense of restlessness and nervousness.

Choice D rationale:

Engaging in physical exercise when experiencing tension in the neck is a productive strategy. Exercise promotes the release of endorphins, which are natural mood lifters and stress reducers.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a mental health clinic is attempting to develop a therapeutic relationship with a client. Which of the following should be the appropriate action by the nurse?

Correct Answer is A

Explanation

A nurse is discussing stress management techniques with a group of clients. Which of the following techniques mentioned by a client should the nurse recognize as the least effective?

Correct Answer is C

Explanation

A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting, and now the client is pacing up and down the hallways of the unit. Which of the following actions should the nurse take?

A nurse is caring for a client who is withdrawing from opioids. Which of the following medications would the nurse prepare to administer?

A home health nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain?

A nurse in the ER is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

The nurse is caring for a client diagnosed with Severe Intellectual Disability. Which of the following characteristics should the nurse recognize to be associated with Severe Intellectual Disability?

A nurse in the acute mental health unit is admitting a new client with an eating disorder. The nurse is aware that which of the following are considered comorbidities of eating disorders? (Select all that apply.)

A nurse is assessing a client who is experiencing stress. The nurse recognizes which of the following is not a predisposing factor for stress?

A nurse is planning a unit orientation for a newly admitted client diagnosed with severe depression. Which of the following should be the nurse's approach?