Forty-eight hours after starting haloperidol, the client is observed standing by the nurse’s station with his neck arched sharply backward. The nurse recognizes that the client:

Is having pseudo-Parkinsonian side effects and needs to have his medication adjusted.

Is experiencing temporary side effects that usually disappear after several days.

Needs to have the dosage increased because of psychotic behavior that is increasing.

Needs immediate treatment and is experiencing an acute dystonic reaction to the drug.

Answer and Explanation

The Correct Answer is D

Choice A Reason:

Pseudo-Parkinsonian side effects, also known as drug-induced parkinsonism, can occur with the use of antipsychotic medications like haloperidol. These side effects include symptoms such as rigidity, bradykinesia, tremor, and postural instability. However, the description of the client’s neck arched sharply backward is more indicative of an acute dystonic reaction rather than pseudo-Parkinsonian side effects. Pseudo-Parkinsonian symptoms typically develop more gradually and do not present with such dramatic posturing.

Choice B Reason:

While some side effects of haloperidol can be temporary and may disappear after several days, the acute dystonic reaction described in the scenario requires immediate intervention. Acute dystonic reactions are characterized by sudden, severe muscle contractions that can be painful and potentially dangerous if they involve the airway. Therefore, it is crucial to address this reaction promptly rather than waiting for it to resolve on its own.

Choice C Reason:

Increasing the dosage of haloperidol in response to the described symptoms would likely exacerbate the situation. The client’s symptoms are not indicative of worsening psychotic behavior but rather an adverse reaction to the medication. Increasing the dosage could lead to more severe side effects and complications. The appropriate response is to treat the acute dystonic reaction and reassess the medication regimen.

Choice D Reason:

An acute dystonic reaction is a known side effect of antipsychotic medications like haloperidol. It involves sudden, severe muscle contractions, often affecting the neck, face, and back. This reaction can be distressing and requires immediate treatment with anticholinergic medications such as benztropine or diphenhydramine. Prompt intervention can relieve the symptoms and prevent further complications.

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Correct Answer is ["C","E"]

Explanation

The correct answer is c, e.

Choice A Reason:

The statement “Clear and organized speech” is incorrect. Clients with delirium often exhibit disorganized thinking and speech. Their speech may be rambling, irrelevant, or incoherent, reflecting their fluctuating mental state. Clear and organized speech is more characteristic of a person without cognitive impairment or with stable cognitive function.

Choice B Reason:

The statement “Increased attention and focus” is incorrect. Delirium is characterized by a disturbance in attention and awareness. Clients with delirium typically have difficulty sustaining or shifting attention, which is a key diagnostic criterion. Increased attention and focus are not consistent with the presentation of delirium.

Choice C Reason:

The statement “Fluctuating levels of consciousness” is correct. One of the hallmark features of delirium is the fluctuation in the level of consciousness throughout the day3. Clients may experience periods of lucidity interspersed with confusion and disorientation. This fluctuation is a critical diagnostic indicator of delirium.

Choice D Reason:

The statement “Stable and consistent cognitive function” is incorrect. Delirium is marked by an acute change in cognitive function, which is neither stable nor consistent. Cognitive functions such as memory, orientation, and language are typically impaired and fluctuate over time. Stable cognitive function would not support a diagnosis of delirium.

Choice E Reason:

The statement “Agitation and aggression” is correct. Clients with delirium often exhibit behavioral disturbances, including agitation and aggression. These symptoms can result from the confusion and disorientation experienced during delirium. Recognizing these behavioral changes is important for the diagnosis and management of delirium.

A. Biofeedback B. Acupuncture C. Reiki D. Autogenic training

Correct Answer is A

Explanation

The correct answer is a.

Choice A Reason:

The statement “Biofeedback” is correct. Biofeedback is a technique that uses electronic monitoring devices to help individuals gain control over involuntary bodily functions such as heart rate, muscle tension, and blood pressure. During biofeedback sessions, sensors are attached to the body to measure physiological functions, and the feedback from these sensors helps clients learn to control their physical responses to stress. This method is particularly effective for managing conditions like chronic pain, anxiety, and hypertension.

Choice B Reason:

The statement “Acupuncture” is incorrect. Acupuncture is a traditional Chinese medicine practice that involves inserting thin needles into specific points on the body to balance the flow of energy or qi. While acupuncture can help manage stress and pain, it does not use electronic monitoring devices to provide feedback on physiological functions5. Instead, it relies on the practitioner’s skill and knowledge of acupuncture points and meridians.

Choice C Reason:

The statement “Reiki” is incorrect. Reiki is a form of energy healing that involves the practitioner placing their hands lightly on or just above the client’s body to channel healing energy. Reiki aims to promote relaxation, reduce stress, and support the body’s natural healing processes. However, it does not involve the use of electronic monitoring devices to provide feedback on physiological functions.

Choice D Reason:

The statement “Autogenic training” is incorrect. Autogenic training is a relaxation technique that involves self-suggestion and visualization to induce a state of relaxation and reduce stress. It focuses on creating sensations of warmth and heaviness in different parts of the body through repeated phrases and mental imagery. While effective for stress management, it does not use electronic monitoring devices to provide feedback on physiological functions.

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Forty-eight hours after starting haloperidol, the client is observed standing by the nurse’s station with his neck arched sharply backward. The nurse recognizes that the client:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is disoriented to time and place. What additional findings would support a diagnosis of delirium? (Select all that apply.)

Correct Answer is ["C","E"]

Explanation

A nurse is preparing a presentation at a community center about complementary and alternative therapies. Which of the following therapies should the nurse describe as the use of an electronic monitoring device to help clients learn to control physical responses to stress?

Correct Answer is A

Explanation

The nurse is teaching a client about lorazepam. The nurse should instruct the client to expect which of the following side effects?

A nurse working on a mental health unit reviews therapeutic and non-therapeutic communication techniques with a student nurse. Which of the following are therapeutic communication techniques? (SELECT ALL THAT APPLY)

Forty-eight hours after starting haloperidol, the client is observed standing by the nurse’s station with his neck arched sharply backward. The nurse recognizes that the client:

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A nurse is caring for a client who has schizophrenia and is experiencing command auditory hallucinations. Which of the following actions should the nurse take?

The nurse calculates that a patient must receive 1.3 mL of an anti-infective agent. The dose is ordered IM. Which of the following choices demonstrates safe, evidence-based practice?

A nurse in orientation is rotating to a psychiatric unit where they observe a client in seclusion. Which of the following statements by the nurse’s preceptor best explains the use of seclusion on a unit?

The nurse is completing an admission assessment of a client who is admitted to milieu. Which piece of information obtained from the client during the assessment would require immediate investigation from the nurse regarding the client’s use of complementary and alternative therapies?