A nurse in a mental health facility is reinforcing teaching to a newly licensed nurse about how to perform an Abnormal Involuntary Movement Scale (AIMS) test on a client. The charge nurse should identify that the AIMS test is used for which of the following conditions?
Lithium toxicity
Alcohol withdrawal
Tardive dyskinesia
Opiate withdrawal
The Correct Answer is C
A. Lithium toxicity. The AIMS test does not assess lithium toxicity. Lithium toxicity is monitored through serum lithium levels and clinical symptoms such as tremors, nausea, confusion, and ataxia. Severe toxicity can lead to seizures, coma, and organ failure, requiring immediate intervention.
B. Alcohol withdrawal. The AIMS test does not assess alcohol withdrawal. Withdrawal symptoms include tremors, hallucinations, seizures, and autonomic instability. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is commonly used to assess symptom severity and guide treatment.
C. Tardive dyskinesia. The AIMS test is used to assess tardive dyskinesia, a movement disorder caused by long-term antipsychotic use. It evaluates involuntary movements of the face, tongue, and extremities, helping clinicians monitor progression and adjust medications to minimize symptoms.
D. Opiate withdrawal. The AIMS test does not assess opiate withdrawal. Symptoms include sweating, agitation, diarrhea, and muscle aches. The Clinical Opiate Withdrawal Scale (COWS) is typically used to assess withdrawal severity and guide opioid detoxification or replacement therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Exhaustion phase. The exhaustion phase occurs when the body's ability to cope with stress is depleted, leading to physical and psychological impairments such as fatigue, burnout, and increased susceptibility to illness. This phase does not align with maintaining performance over an extended period.
B. Alarm phase. The alarm phase is the initial reaction to stress, activating the sympathetic nervous system and triggering the "fight-or-flight" response. While it provides a short-term boost in alertness and energy, it is not sustainable for weeks to months without impairment.
C. Resistance phase. The resistance phase allows the body to adapt to prolonged stress, maintaining homeostasis and function without significant observable impairment. During this phase, the individual continues to perform duties effectively despite ongoing stress.
D. Adaptive phase. The General Adaptation Syndrome does not include an "adaptive phase." Adaptation occurs within the resistance phase, making this answer incorrect.
Correct Answer is C
Explanation
A. Although you have mentioned wanting to talk today about your past abuse, let's discuss this handout I have with new coping skills. Redirecting the client away from their chosen topic disregards their needs and autonomy. Patient-centered care involves respecting the client’s concerns and prioritizing what is most meaningful to them.
B. I am going to have to change our meeting time because I need to go get lunch. Changing the meeting time based on the nurse’s personal needs rather than the client’s schedule does not align with patient-centered care. The focus should remain on the client's well-being and therapeutic relationship.
C. Let's review the goals you set today and see what your priority is this week. Reviewing client-established goals and prioritizing their needs aligns with patient-centered care. This approach fosters collaboration and empowers the client to take an active role in their recovery.
D. I would like to focus on what I believe are the best goals for you to work on. Imposing the nurse’s priorities over the client’s goals does not support patient-centered care. Instead, care should be tailored to the client's preferences, values, and recovery journey.
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