After several days of being despondent and nonverbal, a female client with depression begins to talk and exhibit energy. Which action should the nurse implement?

Involve her in group therapy.

Praise her for the new behavior.

Observe her actions continuously.

Offer her a choice of activities.

Answer and Explanation

The Correct Answer is C

Choice A rationale: Involving her in group therapy may be premature, as the client has just started to exhibit changes in behavior. Continuous observation is necessary to assess the nature and sustainability of these changes.

Choice B rationale: Praising her for the new behavior is positive, but continuous observation is essential to monitor for any signs of escalating or problematic behavior.

Choice C rationale: Observing her actions continuously is the most appropriate action at this point. The nurse needs to monitor the client closely to assess the nature of the changes, ensuring they are not indicative of increased agitation or potential harm.

Choice D rationale: Offering her a choice of activities may be appropriate once the nurse has a better understanding of the clien's current state. However, continuous observation is the priority.

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Correct Answer is A

Explanation

Choice A rationale: Documenting the finding on the Abnormal Involuntary Movement Scale (AIMS) is appropriate. The AIMS is a standardized tool used to assess and document abnormal movements associated with antipsychotic medications, such as tardive dyskinesia.

Choice B rationale: Assisting the client in recognizing her manifestations of anxiety is unrelated to the observed foot tapping and does not address the potential side effects of antipsychotic medication.

Choice C rationale: Preparing to initiate seizure precautions for the client's safety is not indicated based on the observed foot tapping. Seizure precautions are not typically associated with antipsychotic medication side effects.

Choice D rationale: Advising the client that she has developed tolerance to the medication is speculative and not supported by the information provided. The observed foot tapping may be indicative of extrapyramidal side effects rather than tolerance.

A. The drug that was ingested. B. The time since drug ingestion. C. Reason for the suicide attemp D. Past history of depression.

Correct Answer is A

Explanation

Choice A rationale:A. The drug that was ingested is the most important information because knowing the specific substance determines the course of treatment. For example, acetaminophen overdose requires administration of N-acetylcysteine, while opioid overdose requires naloxone. Different drugs have different toxic effects, antidotes, and supportive measures, making this information critical to providing appropriate and potentially life-saving care.

Choice B rationale: The time since drug ingestion is important because many interventions, such as gastric lavage or activated charcoal, are time-sensitive. However, without knowing the specific drug, it is difficult to determine whether these interventions are necessary or effective

Choice C rationale: Knowing the reason for the suicide attempt is important for overall assessment and treatment planning but may not provide immediate information for the current situation.

Choice D rationale: Past history of depression is relevant to the client's overall mental health, but in the context of a suspected drug overdose, the time since ingestion takes precedence.

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After several days of being despondent and nonverbal, a female client with depression begins to talk and exhibit energy. Which action should the nurse implement?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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