A nurse is caring for a client diagnosed with somatic symptom disorder who reports chest pain. Laboratory results and ECG are within normal limits, and the client has no cardiac history. Which of the following nursing actions is most appropriate at this time?

Acknowledge the client’s concerns and redirect focus to coping strategies.

Encourage the client to minimize attention to physical symptoms.

Refer the client for immediate psychiatric evaluation.

Reassure the client that nothing is physically wrong.

Answer and Explanation

The Correct Answer is A

Choice A reason: The most therapeutic approach is to acknowledge the client’s distress and validate their concerns while gently redirecting focus toward coping strategies. This balances empathy with promoting adaptive behaviors. It avoids dismissing the client’s experience and supports long-term management of somatic symptom disorder.

Choice B reason: Encouraging the client to minimize attention to symptoms may appear dismissive and can increase anxiety or mistrust. Clients with somatic symptom disorder often feel invalidated, so this approach is not therapeutic.

Choice C reason: Immediate psychiatric evaluation is not warranted unless there is evidence of acute psychiatric crisis, such as suicidal ideation. In this case, the client’s symptoms are consistent with somatic symptom disorder and can be managed with therapeutic communication and coping strategies.

Choice D reason: Reassuring the client that nothing is physically wrong invalidates their experience and may worsen anxiety. It is not therapeutic and does not promote trust or coping.

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Correct Answer is C

Explanation

Choice A reason: Sodium intake does affect lithium levels because lithium and sodium compete for reabsorption in the kidneys. However, increasing sodium intake is not the immediate intervention for a client with a lithium level of 1.4 mEq/L, which is above the therapeutic range (0.6–1.2 mEq/L). The priority is to prevent further administration and notify the provider.

Choice B reason: Simply documenting and reassessing later delays necessary intervention. Lithium toxicity can progress quickly, and waiting 4 hours without action risks worsening symptoms. This option does not address the immediate safety concern.

Choice C reason: A level of 1.4 mEq/L indicates early lithium toxicity. The nurse should hold the next dose to prevent further accumulation and notify the provider immediately. This action ensures timely medical evaluation and prevents progression to severe toxicity, which can cause neurological and cardiovascular complications.

Choice D reason: Continuing the medication as prescribed would worsen toxicity. Administering lithium at this level is unsafe and contraindicated. This option disregards the abnormal laboratory finding and places the client at risk.

A. Muscle spasms of the neck B. Tremors of the hands C. Sexual dysfunction D. Fidgeting behavior E. Blurred vision

Correct Answer is ["A","B","D"]

Explanation

Choice A reason: Muscle spasms of the neck (torticollis) are a form of acute dystonia, which is a type of EPS. This can be painful and potentially dangerous if it affects airway muscles.

Choice B reason: Tremors of the hands are a sign of parkinsonism, another type of EPS caused by dopamine blockade.

Choice C reason: Sexual dysfunction is a side effect of antipsychotics but is not classified as EPS. EPS specifically refers to motor disturbances.

Choice D reason: Fidgeting behavior can indicate akathisia, an EPS characterized by inner restlessness and inability to remain still.

Choice E reason: Blurred vision is an anticholinergic side effect, not an EPS.

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A nurse is caring for a client diagnosed with somatic symptom disorder who reports chest pain. Laboratory results and ECG are within normal limits, and the client has no cardiac history. Which of the following nursing actions is most appropriate at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory results of a client who is prescribed lithium 300 mg three times daily. The client’s serum lithium level is 1.4 mEq/L. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is ["A","B","D"]

Explanation

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A nurse is caring for a client diagnosed with somatic symptom disorder who reports chest pain. Laboratory results and ECG are within normal limits, and the client has no cardiac history. Which of the following nursing actions is most appropriate at this time?