The nurse is interviewing a newly admitted client. Which of the following nursing statements is an example of offering a "general lead"?

"Can you order the specific events that led to your admission?"

"Do you know why you are here?"

"Are you feeling depressed or anxious?"

"Yes, I see. Go on."

Answer and Explanation

The Correct Answer is D

a. "Can you order the specific events that led to your admission?" This statement directs the client to provide specific information and is more focused than a general lead. It does not encourage a broad response.
b. "Do you know why you are here?" This question is somewhat open-ended but still directs the client's response toward understanding their admission.
c. "Are you feeling depressed or anxious?" This question is specific and closed-ended, prompting a choice between two options rather than encouraging the client to freely elaborate.
d. "Yes, I see. Go on." This is correct because it encourages the client to continue speaking without directing the topic, which is the essence of a general lead.

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Correct Answer is B

Explanation

a. Muscle rigidity and stiffness: This is correct because muscle rigidity and stiffness are signs of extrapyramidal symptoms (EPS), which benztropine is prescribed to treat.
b. Constipation and dry mouth: These are common side effects of antipsychotics but do not warrant benztropine, which is specifically used to manage EPS.
c. Tachycardia and hypotension: These are not related to the EPS that benztropine treats. They may require other interventions.
d. Reports of photosensitivity: Photosensitivity is not related to EPS and does not require benztropine.

A. Altered thought processes; call an emergency treatment team meeting. B. Command hallucinations; warn the psychiatrist. C. Persecutory delusions; orient the client to reality. D. Magical thinking; administer an antipsychotic medication.

Correct Answer is B

Explanation

a. Altered thought processes; call an emergency treatment team meeting. While altered thought processes are present, the urgent concern is the command hallucination directing the client to harm the psychiatrist. An emergency treatment team meeting may not provide the immediate intervention required.
b. Command hallucinations; warn the psychiatrist. This is correct because the client is experiencing command hallucinations that pose a direct threat to the psychiatrist. The nurse has a duty to warn the potential victim and ensure the safety of both the client and others.
c. Persecutory delusions; orient the client to reality. Persecutory delusions are present, but the immediate danger from the command hallucinations takes precedence. Orienting the client to reality does not address the urgent safety issue.
d. Magical thinking; administer an antipsychotic medication. Magical thinking is not the correct symptom here. Administering medication is part of treatment but does not address the immediate safety concern.

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The nurse is interviewing a newly admitted client. Which of the following nursing statements is an example of offering a "general lead"?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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