A nurse is caring for a client who has a new prescription for risperidone. Which of the following rating scales should the nurse complete prior to administering the first dose of risperidone?
The Hamilton Depression Scale
The Body Attitude Test
The Abnormal Involuntary Movement Scale
The Recovery Attitude and Treatment Evaluator
The Correct Answer is C
Choice A reason: The Hamilton Depression Scale is used to assess severity of depression, not antipsychotic side effects.
Choice B reason: The Body Attitude Test is used in eating disorder assessments, unrelated to risperidone therapy.
Choice C reason: The Abnormal Involuntary Movement Scale (AIMS) evaluates for movement disorders like tardive dyskinesia, which are possible side effects of antipsychotics. Baseline assessment is essential before starting treatment.
Choice D reason: The Recovery Attitude and Treatment Evaluator measures patient attitudes about recovery and treatment, not medication side effects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:Regression involves reverting to an earlier developmental stage under stress, such as seeking dependency or avoiding responsibilities like chores and appointments. The client’s desire to be cared for reflects this defense mechanism.
Choice B reason:Introjection involves internalizing others’ beliefs or values, such as adopting someone else’s attitudes. The client’s behavior does not involve adopting external values but rather a retreat to dependency.
Choice C reason:Repression involves unconsciously blocking distressing thoughts or memories. The client’s behavior is not about forgetting stress but actively expressing a need for care, making this incorrect.
Choice D reason:Dissociation involves detaching from reality or one’s sense of self, often in response to trauma. The client’s behavior reflects dependency, not a disconnection from reality, so this is incorrect.
Correct Answer is C
Explanation
Choice A reason: Pseudoparkinsonism causes symptoms such as tremors, rigidity, bradykinesia, and shuffling gait. It is not associated with fever, blood pressure changes, or diaphoresis.
Choice B reason: Tardive dyskinesia develops gradually after prolonged antipsychotic use and presents with involuntary movements like lip smacking, tongue protrusion, or grimacing. It does not cause acute systemic symptoms such as hyperpyrexia or autonomic instability.
Choice C reason: Neuroleptic malignant syndrome (NMS) is a life-threatening emergency associated with antipsychotics. It manifests with hyperpyrexia, autonomic instability (blood pressure changes, diaphoresis), severe muscle rigidity, and altered mental status. The client’s presentation matches NMS.
Choice D reason: Acute dystonia involves sudden muscle contractions affecting the face, neck, or back (e.g., torticollis, oculogyric crisis). It does not present with systemic symptoms like fever or blood pressure fluctuations.
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