The nurse is conducting an assessment for the client, a 5-year veteran with a traumatic brain injury (TBI). He was referred to the clinic for an evaluation of movement disorders. He reports taking alprazolam (Xanax) for the past 3 months and wonders if that is contributing to his tremors and shuffling gait. Which of the following is most important in guiding the nurse’s further assessment and response?
The client's symptoms are most likely symptoms of post-traumatic stress disorder (PTSD).
The client is at risk of Parkinson’s disease.
The client is at high risk of extrapyramidal symptoms (EPS).
The client's symptoms are likely related to an alprazolam (Xanax) addiction.
The Correct Answer is C
Choice A reason: PTSD symptoms include hyperarousal, flashbacks, and avoidance behaviors, not tremors or shuffling gait. Linking these motor symptoms to PTSD is inaccurate.
Choice B reason: Parkinson’s disease involves tremors and shuffling gait, but the client’s medication history and psychiatric background suggest drug-induced movement disorder rather than idiopathic Parkinson’s.
Choice C reason: Extrapyramidal symptoms (EPS) are drug-induced movement disorders commonly associated with antipsychotics, but can also occur with other medications. Tremors and shuffling gait are hallmark EPS features. This is the most important consideration for guiding assessment and response, as medication adjustments may be necessary.
Choice D reason: Alprazolam is a benzodiazepine, and while dependence and withdrawal are concerns, tremors and shuffling gait are not typical signs of addiction. EPS is a more clinically relevant explanation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Encouraging family to meet all self-care needs reduces opportunities for independence. While family support is important, overdependence hinders skill development and autonomy in adolescents with moderate ID.
Choice B reason: Avoiding interference entirely may lead to frustration or unsafe practices. Moderate ID requires structured guidance, not complete independence. Without support, the client may struggle to complete tasks correctly or safely.
Choice C reason: Meeting all self-care needs for the client fosters dependency and prevents skill acquisition. While safety is important, this approach denies the adolescent opportunities to practice and improve self-care abilities.
Choice D reason: Providing simple directions and praising independent efforts is the most appropriate intervention. Adolescents with moderate ID benefit from step-by-step guidance and positive reinforcement. This approach builds confidence, encourages autonomy, and ensures safety while promoting skill mastery.
Correct Answer is A
Explanation
Choice A reason: Double-bind communication occurs when a person conveys two conflicting messages simultaneously, creating confusion. The mother’s statement expresses verbal support (“That’s wonderful”) but also conveys guilt-inducing undertones (“I’ll be fine all alone”). This contradictory communication can create emotional conflict for the son, making it difficult for him to respond appropriately.
Choice B reason: Indirect communication involves conveying a message without stating it clearly. While the mother’s statement has an indirect element, the defining feature here is the contradictory nature of her words, which aligns more with double-bind communication.
Choice C reason: Withholding supportive messages would mean failing to provide encouragement or affirmation. In this case, the mother does provide verbal support (“That’s wonderful”), so she is not withholding supportive communication.
Choice D reason: Denigrating remarks are negative or insulting comments. The mother’s statement is not insulting; rather, it is emotionally conflicting. Therefore, this option does not fit the scenario.
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