A nurse on a mental health unit notices that a client is becoming increasingly agitated and throws a table when he is unable to select the television (TV) channel. Which of the following should be a priority action by the nurse?

Attempt to talk the client down.

Administer a PRN antianxiety medication.

Place the client in a monitored seclusion room until he is calm.

Restrain the client to prevent injury to himself or others.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Attempting to talk the client down is the priority action in this situation. Agitation can escalate to aggression or violence if not addressed appropriately. Engaging in therapeutic communication can help de-escalate the client's agitation, express understanding, and potentially find out the underlying cause of their distress. This approach prioritizes a non-pharmacological intervention.

Choice B rationale:

Administer a PRN antianxiety medication. While medication might be a consideration for managing agitation, it's generally not the first action to take. Non-pharmacological interventions, like therapeutic communication, should be attempted first to minimize the reliance on medications to manage behaviors.

Choice C rationale:

Place the client in a monitored seclusion room until he is calm. Placing a client in seclusion should be a last resort and should only be done when there's an immediate risk of harm to the client or others. In this scenario, the client's agitation doesn't seem to present an imminent danger, so seclusion would be an excessive and restrictive intervention.

Choice D rationale:

Restrain the client to prevent injury to himself or others. Restraint should be an absolute last resort and only used when there's an imminent risk of harm that cannot be managed in any other way. Restraint can escalate agitation and trauma for the client, as well as pose legal and ethical concerns. Therefore, it should only be used when all other options have been exhausted and safety is a critical concern.

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Correct Answer is D

Explanation

The correct answer is choice D: Continuous worry about the undiagnosed presence of an illness.

Choice A rationale:

Sudden unexplained loss of peripheral sensation is not typically associated with illness anxiety disorder. This symptom may be indicative of a neurological condition and would require further medical evaluation to determine the cause.

Choice B rationale:

Obsession over a fictitious defect in physical appearance is more characteristic of body dysmorphic disorder, not illness anxiety disorder. Individuals with body dysmorphic disorder are preoccupied with one or more perceived defects or flaws in their physical appearance, which are not observable or appear slight to others.

Choice C rationale:

Having prior physical health followed by the need for two surgeries within the last three months does not necessarily indicate illness anxiety disorder. This choice does not provide enough context to link it to illness anxiety disorder, as it could be related to many other health conditions.

Choice D rationale:

Continuous worry about the undiagnosed presence of an illness is a key finding in illness anxiety disorder. Individuals with this disorder are excessively concerned with and preoccupied by the belief that they have, or are in danger of developing, a serious undiagnosed illness despite medical reassurance.

A. Neuroleptic malignant syndrome. B. Tardive dyskinesia. C. Acute dystonia. D. Pseudoparkinsonism.

Correct Answer is A

Explanation

Choice A rationale:

Neuroleptic malignant syndrome (NMS) is a potentially life-threatening condition that can occur as a severe adverse effect of antipsychotic medications, such as risperidone (Risperdal). Symptoms of NMS include flu-like symptoms (fever, muscle rigidity, and sweating) along with altered mental status, and autonomic dysregulation. It's crucial for the nurse to recognize this potentially fatal condition promptly and intervene appropriately.

Choice B rationale:

Tardive dyskinesia is a movement disorder that is often a result of long-term use of antipsychotic medications, but it is characterized by repetitive, involuntary movements of the face and other body parts. It doesn't typically present with flu-like symptoms or low blood pressure.

Choice C rationale:

Acute dystonia is characterized by involuntary muscle contractions and spasms, often involving the muscles of the face, neck, and back. It usually occurs shortly after starting antipsychotic treatment. While it can cause discomfort, it doesn't present with flu-like symptoms and low blood pressure as described in the scenario.

Choice D rationale:

Pseudoparkinsonism, also known as drug-induced parkinsonism, is characterized by symptoms similar to Parkinson's disease, such as tremors, bradykinesia (slowness of movement), and rigidity. It doesn't typically cause flu-like symptoms and low blood pressure.

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A nurse on a mental health unit notices that a client is becoming increasingly agitated and throws a table when he is unable to select the television (TV) channel. Which of the following should be a priority action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has illness anxiety disorder. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

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