During group therapy, the nurse observes that a client is pacing, agitated, and presenting with aggressive gestures. The client’s speech pattern is rapid, and affect is belligerent. Based on the observations, the nurse’s immediate priority of care is to:

Assist the staff in caring for the client in a controlled environment

Provide safety for the client and other clients on the unit

Provide the clients on the unit with a sense of comfort and safety

Offer the client a less stimulated area to calm down and gain control

Answer and Explanation

The Correct Answer is B

Choice A reason:
While assisting the staff in caring for the client in a controlled environment is important, the immediate priority is to ensure safety. This choice does not directly address the immediate need to protect all clients from potential harm.

Choice B reason:
Providing safety for the client and other clients on the unit is the immediate priority. The client’s aggressive behavior poses a risk to themselves and others, and ensuring safety is the first step in managing the situation. This involves de-escalation techniques and possibly removing the client from the group setting to prevent harm.

Choice C reason:
Providing a sense of comfort and safety is important but secondary to ensuring immediate physical safety. The client’s aggressive behavior needs to be managed first to prevent any potential harm.

Choice D reason:
Offering the client a less stimulated area to calm down is a good strategy for de-escalation, but it comes after ensuring the immediate safety of all clients. The primary concern is to prevent any aggressive actions that could harm others.

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Correct Answer is D

Explanation

Choice A reason:
Dystonia involves muscle contractions causing twisting and repetitive movements or abnormal postures. It typically occurs early in treatment and affects the neck, face, and back muscles. The involuntary movements described in the scenario are more characteristic of tardive dyskinesia rather than dystonia.

Choice B reason:
Parkinsonism is characterized by symptoms similar to Parkinson’s disease, such as tremors, bradykinesia, and rigidity. While it can occur with long-term use of antipsychotics, the specific involuntary movements of the tongue and face described are more indicative of tardive dyskinesia.

Choice C reason:
Akathisia involves a feeling of inner restlessness and an urgent need to move. It does not typically present with the involuntary movements of the tongue and face described in the scenario. Akathisia is more about the inability to stay still rather than specific muscle movements.

Choice D reason:
Tardive dyskinesia is a well-known adverse effect of long-term antipsychotic use, characterized by repetitive, involuntary movements, especially of the face, tongue, and limbs. The description of involuntary movements of the tongue and face fits the profile of tardive dyskinesia, making it the most likely diagnosis.

A. “What are the voices telling you to do?” B. “You need to understand that there are no voices.” C. “Why do you think you are hearing the voices?” D. “You need to tell the voices to leave you alone.”

Correct Answer is A

Explanation

Choice A reason:
Asking “What are the voices telling you to do?” is an appropriate response because it allows the nurse to assess the content of the hallucinations and determine if the client is at risk of harming themselves or others. This approach shows empathy and concern while gathering important information for the client’s safety.
Choice B reason:
Telling the client “You need to understand that there are no voices” dismisses the client’s experience and can increase their distress. It is important to acknowledge the client’s feelings and perceptions, even if they are not based in reality.
Choice C reason:
Asking “Why do you think you are hearing the voices?” may not be helpful in the moment of distress. The client may not be able to provide a rational explanation for their hallucinations, and this question could increase their confusion and anxiety.
Choice D reason:
Telling the client “You need to tell the voices to leave you alone” may not be effective, as the client may not have the ability to control their hallucinations. It is more important to assess the content of the hallucinations and provide support.

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During group therapy, the nurse observes that a client is pacing, agitated, and presenting with aggressive gestures. The client’s speech pattern is rapid, and affect is belligerent. Based on the observations, the nurse’s immediate priority of care is to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has schizophrenia and has been on long-term treatment with chlorpromazine. He notes the client is experiencing some involuntary movements of the tongue and face. The nurse should suspect the client has developed which of the following adverse effects?

Correct Answer is D

Explanation

A nurse is talking with a client who has schizophrenia. Suddenly the client states, “I’m frightened. Do you hear that? The voices are telling me to do terrible things.” Which of the following responses by the nurse is appropriate?

Correct Answer is A

Explanation

A nurse is developing a plan of care for a newly admitted client who has schizophrenia and experiences frequent hallucinations and paranoid delusions. Which of the following actions should the nurse plan to take?

The nurse calls security and has physical restraints applied to a client who was admitted voluntarily when the client becomes verbally abusive, demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions?

A nurse is providing in-home mental health care and determines that the care is effective when the client demonstrates which response?

A nurse is preparing to assist with electroconvulsive therapy (ECT). Which of the following pieces of equipment should the nurse set up in the room prior to the treatment? (Select all that apply)

A nurse is reviewing the DSM-5 diagnostic criteria for schizophrenia. Which of the following symptoms must be present for a client to be diagnosed with schizophrenia? (Select all that apply.)

A woman comes into the Emergency Department in a severe state of anxiety following a car accident. The appropriate nursing intervention is to:

On review of the client’s record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care anticipating which client behavior?