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 C

Explanation

A. Sharing personal values may blur professional boundaries and could potentially influence the client's responses, which is not appropriate in a therapeutic setting.
B. Asking questions in a vague, non-specific format may not yield accurate or detailed information about the client's suicidal ideations.
C. Beginning with less sensitive questions allows the client to gradually build trust and rapport with the nurse before addressing more sensitive topics like suicidal ideation.
D. Getting the most difficult questions over with first may overwhelm the client and hinder the development of trust and rapport, which are crucial for effective communication in addressing sensitive topics like suicidal ideation.

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 D

Explanation

A. Asking the client to describe and identify feelings is more appropriate for a client with mild to moderate anxiety, not severe anxiety.
B. Providing education is ineffective during severe anxiety because the client is unable to process new information.
C. Relaxation techniques are difficult for a client to use during severe anxiety due to impaired concentration and focus.
D. Reducing environmental stimuli by escorting the client from the group is the best intervention for severe anxiety, as it helps the client regain control and lowers anxiety levels.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is C

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 D

Explanation

The nurse has received a new prescription for the client to begin taking sertraline. Prior to administering the initial dose of sertraline, it is most important for the nurse to obtain which information?

A client who has agoraphobia is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?

The nurse is admitting a male client who takes lithium carbonate twice a day. Which information should the nurse report to the healthcare provider immediately?

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?

The nurse is performing intake interviews at a psychiatric clinic. A client with a known history of drug abuse reports having had a heart attack four years ago. Use of which substance places the client at highest risk for myocardial infarction?