A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit’s day room. Which action should the nurse implement first?

Sit in the chair next to the client.

Listen to what the client is saying.

Escort the client to his room.

Administer a PRN sedative.

Answer and Explanation

The Correct Answer is B

A.   Sitting in the chair next to the client may be a supportive action but does not address the immediate concern of the client's behavior.
B.   Listening to what the client is saying is crucial to understand the content and nature of the auditory hallucinations, which can guide further interventions.
C. Escorting the client to his room may be necessary if the behavior poses a risk, but understanding the content of the hallucinations should precede immediate removal.
D.   Administering a PRN sedative may be considered later based on the assessment, but understanding the nature of the hallucinations and the client's current state is the priority.

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Correct Answer is D

Explanation

A. The healthcare provider's history and physical may provide information about the client's overall health but may not specifically address the observed symptoms.
B. Recent urine drug testing (UDT) results may reveal drug use but may not be directly related to the observed involuntary movements.
C. The baseline nursing admission assessment may provide general information but may not specifically address medication side effects.
D. The Abnormal Involuntary Movement Scale (AIMS) is specifically designed to assess and document involuntary movements associated with psychotropic medications, making it the most relevant assessment tool in this situation.

A. Why do you think you have a hostile work environment? B. Have you considered resigning from your position? C. Have the feelings associated with these events brought you to the clinic? D. How have you responded to those in your work environment about these events?

Correct Answer is C

Explanation

A. This question may be perceived as confrontational. It is essential to explore the client's feelings and experiences first.
B. Asking about resignation is premature at this stage. Exploring feelings and experiences is more appropriate initially.
C. This response acknowledges the client's feelings and experiences, allowing for further exploration of the issues that brought him to the clinic.
D. This question is more focused on the client's actions rather than exploring the emotional impact of the events. The nurse should first understand the client's feelings before addressing actions or solutions.

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A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit’s day room. Which action should the nurse implement first?

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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 C

Explanation

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