A client requests permission for the spouse to remain in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client's verbal and nonverbal communication. Which action should the nurse take?

Ignore the nonverbal behavior and focus on the client's verbal messages.

Integrate the verbal and nonverbal messages and interpret them as one.

Ask the client's spouse to interpret the discrepancy.

Pay close attention and document the nonverbal messages.

Answer and Explanation

The Correct Answer is D

A.   Ignoring nonverbal behavior may overlook important cues that could provide valuable insight into the client's condition and needs.
B.   Integrating verbal and nonverbal messages is important, but it may not address the discrepancy or the potential significance of the nonverbal cues.
C.   Asking the client's spouse to interpret the discrepancy may not be appropriate or effective, as the spouse may not fully understand the client's nonverbal cues or their significance.
D.   Paying close attention and documenting nonverbal messages allows the nurse to gather comprehensive data and potentially explore the observed discrepancy further in subsequent interactions or assessments.

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Correct Answer is A

Explanation

A. Current vital signs are essential for assessing for neuroleptic malignant syndrome (NMS), a potentially life-threatening side effect of antipsychotic medications like haloperidol. Vital signs such as temperature, blood pressure, heart rate, and respiratory rate are crucial indicators of
NMS.

B. While monitoring white blood cell count may be important for detecting infections or adverse reactions to medications, it is not specific to assessing for NMS.
C. Monitoring 24-hour urinary output may be important for assessing renal function but is not specific to assessing for NMS.
D. Monitoring blood sugar levels may be important for clients with diabetes or those at risk of hyperglycemia due to medication effects, but it is not specific to assessing for NMS.

A. Ask the client to describe and identify the source of the feelings. B. Provide education about ways to cope with anxiety. C. Assist the client with relaxation techniques in the group. D. Escort the client from the group to reduce stimuli.

Correct Answer is C

Explanation

A. While it's important for the client to explore the source of their anxiety, this may not be the most appropriate intervention during a group therapy session where immediate relief is needed.
B. Providing education about coping mechanisms is valuable, but it may not address the client's immediate needs for anxiety reduction in the group setting.
C. Assisting the client with relaxation techniques in the group is the best intervention as it provides immediate support and can help alleviate the client's anxiety in the moment.

D. Escorting the client from the group to reduce stimuli may be appropriate if the anxiety becomes overwhelming, but it should be considered after attempting relaxation techniques within the group setting.

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A client requests permission for the spouse to remain in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client's verbal and nonverbal communication. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for neuroleptic malignant syndrome (NMS), which information is most important for the nurse to obtain during this visit?

Correct Answer is A

Explanation

A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

Correct Answer is C

Explanation

Which is the best approach for the nurse to use when interviewing a client about suicidal ideations?

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

A young female client is admitted to the emergency room because she was raped that evening by her date. Which computer documentation should the nurse enter in the electronic medical record as the client's chief complaint?

The nurse is performing the admission assessment for a client with schizophrenia in an acute care inpatient facility. The nurse should identify which observed behavior is characteristic of schizophrenia?