A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone. When the client walks to the nurse's station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the nurse take?

Administer the prescribed anticholinergic benztropine for dystonia.

Offer the client a prescribed physical therapy hot pack for muscle spasms.

Direct the client to occupational therapy to distract him from somatic complaints.

Medicate the client with the prescribed antipsychotic thioridazine.

Answer and Explanation

The Correct Answer is A

A.   The client's symptoms, including a laterally contracted position and perception of body contortion, suggest acute dystonia, a known side effect of antipsychotic medications like risperidone. Administering an anticholinergic such as benztropine can help alleviate these symptoms.
B.   Offering a hot pack for muscle spasms may provide some relief for generalized muscle discomfort but would not specifically address the dystonic reaction.
C.   Directing the client to occupational therapy may be beneficial for overall treatment but does not address the immediate need to alleviate acute dystonic symptoms.
D.   Thioridazine is an antipsychotic medication but is not typically used as a first-line treatment for acute dystonia. Administering benztropine, an anticholinergic, would be more appropriate for dystonia associated with risperidone use.

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Correct Answer is D

Explanation

Rationale for A: The phrase "Client claims" may imply doubt or a lack of belief in the client's account. It's important to use non-judgmental language that reflects the client's words without interpretation or bias. This choice is less appropriate because it doesn't use the client's exact words.

Rationale for B: This statement generalizes the situation and lacks the specificity of the client’s actual words. It may not capture the emotional impact or the client's clear identification of the event as rape. Direct quotations are preferred for documenting sensitive situations like this.

Rationale for C: While "Client has been sexually assaulted" is accurate, it is a general term. It is preferable to document the client's own words verbatim in the medical record to ensure clarity and to avoid any misinterpretation or assumptions.

Rationale for D: Documenting the client's exact words ("My date raped me tonight") ensures that the medical record accurately reflects the client's experience without interpretation. It is crucial to use the client's own language when documenting incidents of sexual assault.

A. "I understand that you're angry and unhappy. Let's explore ways in which you overreact." B. "I hear your frustration about losing control. Tell me how this affects your daily life." C. "Knowing the cause of your symptoms will make them easier to handle." D. "Do all that you can to learn all that you can while you are here. You can get better."

Correct Answer is B

Explanation

A. This comment may come across as invalidating the client's feelings by assuming overreaction, which could potentially escalate the situation.
B. This response acknowledges the client's feelings and invites further exploration, fostering a therapeutic relationship and understanding of the client's experiences.
C. While understanding the cause of symptoms is important, it may not necessarily make them easier to handle, and it could divert focus from addressing the client's immediate concerns.
D. While encouragement is positive, this comment does not directly address the client's feelings or concerns, which is essential for building a therapeutic relationship.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

A client is admitted to the mental health unit with a bipolar disorder. When seeking to establish a therapeutic relationship and interacting with the client, which comment is best for the nurse to make?

Correct Answer is B

Explanation

The nurse develops a plan of care for a female client who scratches her wrists in attempts to deal with anxiety. Which client outcome is most important to include in the plan of care?

The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

Which individual should the nurse consider at highest risk for suicide?