The nurse is admitting a client who has not slept in three days to the inpatient care facility. The client has pressured speech and describes an increase in sexual promiscuity. Which problem should the nurse include in the client's plan of care?

Disturbed personal identity.

Risk for injury.

Ineffective coping.

Anxiety, panic.

Answer and Explanation

The Correct Answer is B

A) Disturbed personal identity could be relevant in the context of a mental health issue, but it is not the most immediate concern given the client's current presentation. While it may be important to address over time, it does not take precedence in the acute phase.

B) Risk for injury is the most critical problem to include in the client's plan of care. The client's lack of sleep, pressured speech, and increase in sexual promiscuity indicate a potential manic episode, which can lead to impulsive and unsafe behaviors. Prioritizing the risk for injury ensures the safety of the client and others, making it essential for the immediate care plan.

C) Ineffective coping is a concern that may develop in response to the client's current symptoms. However, addressing immediate safety needs is more urgent than focusing on coping mechanisms at this point.

D) Anxiety and panic might be present, but they are not as clearly defined in the client's current symptoms as the risk for injury. The focus should remain on preventing harm and ensuring the client is safe during this acute episode.

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Correct Answer is D

Explanation

A) Reviewing the healthcare provider's history and physical may provide some background on the client's overall health and medication history, but it won't specifically address the symptoms currently being observed. While this information is useful, it does not directly relate to the assessment of involuntary movements.

B) The baseline nursing admission assessment can offer insights into the client's initial condition and any prior neurological assessments. However, it may not contain the specific details necessary to evaluate the current symptoms of uncontrollable hand movements and tongue protrusion, which are indicative of potential tardive dyskinesia or other movement disorders.

C) Recent urine drug testing (UDT) results could help identify any illicit substance use or non-compliance with prescribed medications. However, UDT results would not provide a clear correlation to the motor symptoms observed. Understanding the client’s current medication compliance is important, but it is not as directly relevant as the assessment of involuntary movements.

D) Reviewing the Abnormal Involuntary Movement Scale (AIMS) is crucial, as it specifically assesses involuntary movements associated with the use of antipsychotic medications and other psychotropic drugs. AIMS can provide baseline data and track any changes in involuntary movements over time. Given the client's symptoms of uncontrollable hand movements and excessive tongue protrusion, AIMS results will be key to determining if the client is experiencing tardive dyskinesia or other medication-related side effects.

A. Move to a quiet area and provide peanut butter with crackers. B. Encourage the spouse to eat lunch with the client. C. Walk with the client to the cafeteria and stay while client eats. D. Request a full lunch tray from the dietary department.

Correct Answer is C

Explanation

A) Moving to a quiet area and providing peanut butter with crackers may help address the client’s nutritional needs, but it may not adequately address the client’s agitation and pacing. The immediate priority is to stabilize the client’s behavior before focusing on nutrition.

B) Encouraging the spouse to eat lunch with the client may create an opportunity for social interaction, but it might not be effective in calming the client’s agitation. If the client is already highly agitated, the spouse's presence alone may not help diffuse the situation.

C) Walking with the client to the cafeteria and staying while the client eats is the best intervention at this time. This approach allows the nurse to provide a calming presence and guidance while encouraging the client to eat. It also helps redirect the client's energy and agitation into a structured activity, promoting both physical movement and nutrition, which is crucial after several days without food.

D) Requesting a full lunch tray from the dietary department could provide a more substantial meal; however, it might not address the immediate need for calming the client. If the client remains agitated and loud, it may be challenging to ensure that they can eat peacefully, making this intervention less effective than accompanying the client directly to eat.

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The nurse is admitting a client who has not slept in three days to the inpatient care facility. The client has pressured speech and describes an increase in sexual promiscuity. Which problem should the nurse include in the client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client's record should the nurse review?

Correct Answer is D

Explanation

A client with bipolar disorder has not slept or eaten in four days. The client is pacing and becomes increasingly agitated and loud while the nurse talks to the client's spouse. Which intervention is best for the nurse to implement at this time?

Correct Answer is C

Explanation

The healthcare provider prescribes lithium carbonate for a client diagnosed with bipolar, manic depression. It is most important for the nurse to review which laboratory finding prior to beginning the drug therapy?

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