A nurse is responding to a client diagnosed with acute trauma disorder following the sudden death of their child. The client is pacing, wringing their hands, and crying stating "I am just so angry!" The client's vital signs are heart rate 108/min, blood pressure 142/82 mm Hg, and respiratory rate 24/min with shallow respirations. Which of the following nursing actions should the nurse take?

Keep hands where the client can see them.

Acknowledge what the client is experiencing and willingness to help.

Ensure the client has adequate personal space.

Touch the client to show compassion.

Use humor and maintain a constant smile.

Insist that the client calm down immediately.

Answer and Explanation

Correct Answer : A,B,C

Choice A reason: Keeping hands visible is an essential safety measure when interacting with a client experiencing acute trauma and heightened agitation. This action reduces the client’s perception of threat and helps maintain trust. Clients in acute distress may misinterpret hidden movements as threatening, so visible hands reassure them that the nurse is non-threatening and safe.

Choice B reason: Acknowledging the client’s feelings and expressing willingness to help is a therapeutic communication technique. It validates the client’s emotions, shows empathy, and builds rapport. In acute trauma, clients often feel overwhelmed and misunderstood; acknowledgment helps them feel supported and less isolated. This approach also de-escalates emotional intensity by demonstrating that the nurse is present and attentive.

Choice C reason: Ensuring adequate personal space is critical when a client is agitated and pacing. Crowding or standing too close can increase anxiety and escalate anger. Providing space respects the client’s need for autonomy and reduces the risk of physical confrontation. It also allows the client to move freely, which can help discharge some of the heightened energy associated with trauma.

Choice D reason: Touching the client to show compassion is contraindicated in this situation. Physical contact may be misinterpreted as invasive or threatening, especially when the client is angry and emotionally unstable. Instead of calming, touch could escalate agitation or trigger further distress.

Choice E reason: Using humor and maintaining a constant smile is inappropriate in acute trauma. Humor may minimize or invalidate the client’s grief and anger, while a constant smile can appear insincere or dismissive. This approach risks damaging trust and worsening the client’s emotional state.

Choice F reason: Insisting that the client calm down immediately is ineffective and potentially harmful. Trauma responses are involuntary, and demanding calmness invalidates the client’s experience. It can escalate anger and resistance, making the situation more volatile. Supportive, empathetic interventions are far more effective in promoting emotional regulation.

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Correct Answer is C

Explanation

Choice A reason: Requiring excessive advice before making decisions is more characteristic of dependent personality disorder, where individuals rely heavily on others to make choices and feel incapable of functioning independently.

Choice B reason: Believing one’s achievements are superior to others is a hallmark of narcissistic personality disorder. This involves grandiosity, a need for admiration, and a lack of empathy, which differs from the rigid perfectionism seen in obsessive-compulsive personality disorder.

Choice C reason: Being preoccupied with maintaining order by following rigid rules is a defining feature of obsessive-compulsive personality disorder. Clients with this disorder are perfectionistic, inflexible, and excessively focused on rules, order, and control. This often interferes with their ability to adapt and can cause distress in interpersonal relationships.

Choice D reason: Using physical appearance to make others take notice is more typical of histrionic personality disorder, where individuals seek attention through dramatic, emotional, or seductive behavior. This is not consistent with obsessive-compulsive personality disorder, which is focused on control and order rather than attention-seeking.

A. A reaction to drinking grapefruit juice with the medication. B. Early symptoms of tardive dyskinesia. C. Missing a dose of the medication. D. Early symptoms of a psychotic episode.

Correct Answer is B

Explanation

Choice A reason: Grapefruit juice can interact with certain medications, particularly those metabolized by the cytochrome P450 system, but fluphenazine is not significantly affected by grapefruit juice. The symptoms described tongue protrusion and irregular limb movements are not related to food-drug interactions but rather to neurological side effects.

Choice B reason: The protrusion of the tongue and irregular limb movements are hallmark early signs of tardive dyskinesia, a serious extrapyramidal side effect of long-term antipsychotic use. Tardive dyskinesia involves involuntary, repetitive movements, often of the face, tongue, and extremities. Identifying these symptoms early is crucial because tardive dyskinesia can become irreversible if not addressed promptly.

Choice C reason: Missing a dose of fluphenazine would more likely result in a return of psychotic symptoms rather than involuntary motor movements. The described symptoms are not consistent with medication noncompliance but rather with adverse effects of continued use.

Choice D reason: Early symptoms of a psychotic episode typically include hallucinations, delusions, disorganized thinking, or paranoia. Motor symptoms such as tongue protrusion and limb movements are not characteristic of psychotic relapse but are instead linked to medication side effects.

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has obsessive-compulsive personality disorder. Which of the following findings should the nurse include?

Correct Answer is C

Explanation

A nurse is collecting data from a client who has schizophrenia and is taking fluphenazine. The nurse observes that the client’s tongue is protruding and he has irregular movements of his limbs. The nurse should identify that the client is exhibiting manifestations of which of the following?

Correct Answer is B

Explanation

A nurse is monitoring a client who has been diagnosed with post-traumatic stress disorder (PTSD). The nurse recognizes that people diagnosed with PTSD may exhibit symptoms similar to which of the following mental health disorders?

A nurse is caring for a client who is experiencing auditory hallucinations. Which of the following responses should the nurse make first?

A nurse is caring for a client who is taking clozapine for the treatment of schizophrenia. The nurse should monitor the client for which of the following potential adverse effects of clozapine?

A nurse in an outpatient mental health clinic is discussing the development of anxiety-related disorders in children to a group of parents. The nurse should include that which of the following is an adverse childhood experience (ACE) that can contribute to the development of an anxiety disorder?

A nurse is assisting with teaching a class about the general adaptive syndrome. The nurse should include that which of the following manifestations occur during the exhaustion stage?

A nurse is caring for a client who has delusional behavior. The client states, "I can't go to group today. I am expecting a high level official to visit me!" Which of the following responses should the nurse make?

A nurse is assisting in the care of a client who is experiencing excessive anxiety and worry in response to a variety of circumstances, and is unable to control their sense of worry. The nurse should identify that these manifestations indicate which of the following?

A nurse is assisting with the plan of care for a client who was recently diagnosed with a trauma-related disorder. Which of the following client goals should the nurse include?