An adolescent who was arrested a month ago for gang-related activities has a court order to attend weekly group therapy sessions at the mental health clinic. Today the adolescent's mother calls the clinic nurse to report that her child became angry last night and put a fist through a window. Which intervention is most important for the nurse to implement?

Reinforce the need for the adolescent to attend group therapy sessions.

Tell the mother to describe her feelings of helplessness to her child.

Advise the mother to call the police if violent behavior occurs again.

Refer the mother for psychiatric evaluation for anxiety and depression.

Answer and Explanation

The Correct Answer is C

A. While reinforcing the need for group therapy sessions is important, it does not address the immediate safety concerns associated with violent behavior. Therapy is a long-term solution, but immediate action is necessary to prevent harm.
B. Telling the mother to describe her feelings of helplessness to the adolescent is not appropriate. It may increase the adolescent's frustration or aggression, rather than de-escalating the situation.
C. Advising the mother to call the police if violent behavior occurs again is the most important intervention. Violent actions, such as putting a fist through a window, indicate a risk for harm to self or others, and law enforcement intervention may be needed to ensure safety.
D. Referring the mother for psychiatric evaluation may be helpful if she is experiencing anxiety or depression, but it does not address the immediate concern of the adolescent's violent behavior.

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Correct Answer is A

Explanation

A. The client's symptoms, including a laterally contracted position and perception of body contortion, suggest acute dystonia, a known side effect of antipsychotic medications like risperidone. Administering an anticholinergic such as benztropine can help alleviate these symptoms.
B. Offering a hot pack for muscle spasms may provide some relief for generalized muscle discomfort but would not specifically address the dystonic reaction.
C. Directing the client to occupational therapy may be beneficial for overall treatment but does not address the immediate need to alleviate acute dystonic symptoms.
D. Thioridazine is an antipsychotic medication but is not typically used as a first-line treatment for acute dystonia. Administering benztropine, an anticholinergic, would be more appropriate for dystonia associated with risperidone use.

A. A middle-aged man who is complaining of shortness of breath and is diaphoretic. B. A young woman who suddenly goes blind with no indication of organic pathology. C. An older adult who continuously complains of a headache and back pain. D. An adolescent who becomes extremely anxious about going outside.

Correct Answer is B

Explanation

A. Shortness of breath and diaphoresis are more indicative of a medical condition such as a panic attack or cardiovascular problem rather than a conversion disorder.
B. Sudden blindness with no organic pathology suggests a functional neurological symptom disorder, which falls under the category of conversion disorder.
C. Continuous complaints of headache and back pain could be symptoms of various medical conditions and may not specifically indicate a conversion disorder.
D. Extreme anxiety about going outside may indicate agoraphobia or another anxiety disorder rather than a conversion disorder.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?

Correct Answer is B

Explanation

An adult female client is brought to the Emergency Center after fainting at work. The nurse completes an assessment of the client and identifies caregiver role strain as a nursing problem. Which information best supports this problem?

A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for neuroleptic malignant syndrome (NMS), which information is most important for the nurse to obtain during this visit?

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

Which individual should the nurse consider at highest risk for suicide?

A client requests permission for the spouse to remain in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client's verbal and nonverbal communication. Which action should the nurse take?

The nurse is admitting a male client who takes lithium carbonate twice a day. Which information should the nurse report to the healthcare provider immediately?

The nurse wants to teach the client about the long-term phase symptoms of rape-trauma syndrome. What symptoms are consistent with long-term rape trauma? Select all that apply.

Which intervention(s) should the nurse include in the plan of care for an adolescent client who is depressed? Select all that apply.