A client with severe and persistent mental illness has been taking antipsychotic medication for 20 years. The nurse observes during a therapy session that the client's behavior includes repetitive movements of the mouth and tongue, facial grimacing, and rocking back and forth. Which action will the nurse take to address these findings?

Stop the medication immediately and inform the health care provider

Request the client make an effort to remain still for 15 minutes

Administer haloperidol IM to stop the movements

Assess the client using the Abnormal Involuntary Movements Scale (AIMS)

Answer and Explanation

The Correct Answer is D

A. Stop the medication immediately and inform the health care provider: Abruptly discontinuing long-term antipsychotic therapy can lead to withdrawal symptoms and relapse of psychosis. Although the movements suggest tardive dyskinesia, the appropriate first step is structured assessment rather than immediate discontinuation.

B. Request the client make an effort to remain still for 15 minutes: Voluntary suppression of involuntary movements is not feasible in tardive dyskinesia. Asking the client to remain still minimizes the seriousness of the symptoms and does not provide a valid clinical approach.

C. Administer haloperidol IM to stop the movements: Haloperidol is a first-generation antipsychotic that can worsen tardive dyskinesia rather than improve it. Administering more dopamine-blocking medication increases the risk of exacerbating involuntary movements.

D. Assess the client using the Abnormal Involuntary Movements Scale (AIMS): The AIMS tool provides a systematic method for evaluating and documenting the severity of tardive dyskinesia. Accurate assessment helps guide decisions regarding medication adjustment and ongoing monitoring by the healthcare provider.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. "I can use a regular toothbrush but brush gently.": Clients receiving chemotherapy and radiation often develop thrombocytopenia or mucositis. A regular toothbrush can cause gum trauma and bleeding. The client should use a soft-bristled toothbrush or foam swabs to reduce oral injury and infection risk.

B. "I should balance my activities throughout the day to allow for rest periods.": Fatigue is a major side effect of cancer treatment, and conserving energy through activity pacing helps maintain independence while preventing exhaustion.

C. "I should include frequent small meals throughout the day.": Nausea, anorexia, and altered taste are common treatment side effects. Smaller meals are easier to tolerate and help maintain adequate nutrition and caloric intake.

D. "I should use an electric razor.": Due to potential thrombocytopenia and bleeding risk, electric razors are recommended instead of blades to minimize cuts and reduce complications during treatment.

A. Schedule a chest x-ray to evaluate for active pulmonary tuberculosis B. Instruct the client to begin a full course of antitubercular medications immediately C. Repeat the Mantoux test in 3 months to confirm the result D. Document the result as negative since the client has no symptoms

Correct Answer is A

Explanation

A. Schedule a chest x-ray to evaluate for active pulmonary tuberculosis: A positive Mantoux test with induration ≥10 mm in a client without prior TB exposure indicates possible latent TB infection. A chest x-ray is necessary to rule out active disease before initiating treatment and to guide further management.

B. Instruct the client to begin a full course of antitubercular medications immediately: Starting treatment without confirming whether the infection is latent or active could be inappropriate and may lead to unnecessary drug exposure and side effects. Confirmation through imaging and possibly further testing is required first.

C. Repeat the Mantoux test in 3 months to confirm the result: Repeating the test is not necessary because an induration of 12 mm already meets the criteria for a positive result in most adults. Delaying further evaluation could postpone appropriate diagnosis and management.

D. Document the result as negative since the client has no symptoms: Absence of symptoms does not rule out latent tuberculosis. Documenting the result as negative would be inaccurate and could delay treatment or preventive measures, increasing the risk of future disease activation.

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Naxlex Comprehensive Predictor Exams

Which of the following statements by the client requires additional teaching regarding managing side effects of radiation and chemotherapy?

Correct Answer is A

Explanation

A client receives a positive Mantoux tuberculin skin test with an induration measuring 12 mm. The client is asymptomatic and has no history of prior tuberculosis (TB) exposure or vaccination. Which action should the nurse anticipate next?

Correct Answer is A

Explanation

The nurse is educating a client taking Clozaril/clozapine. Which statement made by the client indicates that the education is effective?

A nurse is caring for a patient diagnosed with schizophrenia. The patient is exhibiting disorganized speech, incoherent thoughts, and an inability to perform activities of daily living. Which of the following interventions would be most appropriate to improve the patient's functioning?

A client diagnosed with cancer is receiving chemotherapy. The nurse should assess which diagnostic laboratory value while the client is receiving chemotherapy?

The nurse is preparing a plan of care for a client with dependent personality disorder and assigns an outcome to increase problem-solving skills. Which client behavior would indicate progress toward meeting that outcome?

The nurse explains to the client that therapy will be a long process. Which is a realistic outcome for a client with a personality disorder engaging in therapy?

While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication?

The nurse is involved in the care of a client with antisocial personality disorder. Which purpose does the nurse identify as a priority when participating in a periodic team meeting when caring for this client?