A male client with a long history of alcohol dependency arrives in the Emergency Department describing the feeling of bugs crawling on his body. His blood pressure is 170/102 mm Hg, pulse rate is 110 beats/minute, and blood alcohol level (BAL) is 0 mg/dL. Which prescription should the nurse administer?

Haloperidol.

Lorazepam.

Diphenyhydramine.

Thiamine.

Answer and Explanation

The Correct Answer is B

A) Haloperidol is an antipsychotic that may be used for agitation or hallucinations, but it is not the first-line treatment for alcohol withdrawal symptoms. Administering haloperidol without addressing withdrawal may not be effective and could lead to further complications.

B) Lorazepam is a benzodiazepine and is the preferred medication for managing alcohol withdrawal symptoms, including agitation, anxiety, and hallucinations. It helps reduce the risk of severe withdrawal symptoms and seizures while providing sedative effects. Given the client’s symptoms of feeling bugs crawling on his body, which may indicate tactile hallucinations due to withdrawal, lorazepam would be the most appropriate choice.

C) Diphenhydramine is an antihistamine that can be used for allergic reactions or as a sedative, but it is not effective for managing alcohol withdrawal symptoms.

D) Thiamine is important to prevent Wernicke's encephalopathy in clients with a history of alcohol dependency, especially if there are signs of confusion or neurological deficits. However, it does not address the immediate symptoms of withdrawal the client is experiencing.

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Correct Answer is D

Explanation

A) Reviewing the healthcare provider's history and physical may provide some background on the client's overall health and medication history, but it won't specifically address the symptoms currently being observed. While this information is useful, it does not directly relate to the assessment of involuntary movements.

B) The baseline nursing admission assessment can offer insights into the client's initial condition and any prior neurological assessments. However, it may not contain the specific details necessary to evaluate the current symptoms of uncontrollable hand movements and tongue protrusion, which are indicative of potential tardive dyskinesia or other movement disorders.

C) Recent urine drug testing (UDT) results could help identify any illicit substance use or non-compliance with prescribed medications. However, UDT results would not provide a clear correlation to the motor symptoms observed. Understanding the client’s current medication compliance is important, but it is not as directly relevant as the assessment of involuntary movements.

D) Reviewing the Abnormal Involuntary Movement Scale (AIMS) is crucial, as it specifically assesses involuntary movements associated with the use of antipsychotic medications and other psychotropic drugs. AIMS can provide baseline data and track any changes in involuntary movements over time. Given the client's symptoms of uncontrollable hand movements and excessive tongue protrusion, AIMS results will be key to determining if the client is experiencing tardive dyskinesia or other medication-related side effects.

A. Regression. B. Denial. C. Projection. D. Repression.

Correct Answer is D

Explanation

A) Regression involves reverting to earlier developmental behaviors in response to stress. While the client’s current behaviors may reflect regression, her inability to remember specific events points more directly to another mechanism.

B) Denial is the refusal to accept reality or facts. The client acknowledges that her mother ran her father off, so she is not completely denying her past; instead, she seems to lack memory about certain aspects, which suggests a different mechanism.

C) Projection involves attributing one’s own unacceptable feelings or thoughts to someone else. The client is not projecting her feelings onto others; she is reflecting on her own experiences, so this is not the most accurate descriptor.

D) Repression is the unconscious blocking of unacceptable thoughts or memories. The client’s statement about not remembering possible abuse suggests that she may have repressed those memories as a way to cope with the emotional pain associated with her past. This aligns well with the client’s history of chronic depression and suicidal behavior.

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Naxlex Comprehensive Predictor Exams

When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client's record should the nurse review?

Correct Answer is D

Explanation

Correct Answer is D

Explanation

After several days of being despondent and nonverbal, a female client with depression begins to talk and exhibit energy. Which action should the nurse implement?

The nurse is leading a group on the inpatient psychiatric unit. Which approach should the nurse use during the working phase of group development?

The mental health team working with a homeless client with chronic schizophrenia establishes the treatment goal of, "Improvement in avolition prior to discharge." Which behavior demonstrates achievement of this goal to the nurse?

A young adult client is brought to the emergency department with a suspected drug overdose. Which information is most important for the nurse to obtain from the family?

A client with bipolar disorder has not slept or eaten in four days. The client is pacing and becomes increasingly agitated and loud while the nurse talks to the client's spouse. Which intervention is best for the nurse to implement at this time?

The healthcare provider prescribes lithium carbonate for a client diagnosed with bipolar, manic depression. It is most important for the nurse to review which laboratory finding prior to beginning the drug therapy?

A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client's rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?