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 D
Explanation
A. Inform the newly licensed nurse that they are successfully building trust and rapport. While therapeutic communication is essential, personalizing the interaction in this way crosses professional boundaries. Comparing a client to a family member can create unrealistic expectations and blur the nurse-client relationship. Maintaining professional distance ensures objective and ethical care.
B. Ask the newly licensed nurse if they are comfortable providing care to the client. While assessing a nurse’s comfort level is important, it does not address the boundary violation. The concern is not about the nurse's comfort but about maintaining professionalism in client interactions. Direct intervention is needed to correct the inappropriate statement and reinforce professional conduct.
C. Record that the newly licensed nurse is able to maintain professional nurse-client boundaries. The statement made by the newly licensed nurse demonstrates a boundary issue rather than professionalism. Nurses should establish rapport without over-identification with clients. Documenting that the nurse maintained boundaries would be inaccurate and fail to address the issue.
D. Assign the newly licensed nurse to a different client. The statement suggests an emotional attachment that may interfere with objective care. Reassigning the nurse prevents further boundary issues and allows for education on maintaining professionalism. Ensuring appropriate nurse-client relationships promotes ethical practice and patient-centered care.
Correct Answer is C
Explanation
A. Dialectical behavior therapy. Dialectical behavior therapy is primarily used for borderline personality disorder, focusing on emotional regulation, distress tolerance, and mindfulness. It is not the primary therapy for avoidant personality disorder.
B. Antipsychotic medications. Antipsychotic medications are typically used to manage symptoms of psychotic disorders such as schizophrenia. Avoidant personality disorder does not involve psychosis and is better managed with psychotherapy.
C. Interpersonal therapy. Interpersonal therapy is beneficial for avoidant personality disorder as it focuses on improving social skills, self-esteem, and communication. This therapy helps clients develop healthier relationships and overcome fears of rejection.
D. Antidepressant medications. While antidepressants may be used to treat co-occurring conditions such as depression or anxiety, they do not directly address the core features of avoidant personality disorder. Psychotherapy remains the primary treatment.
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