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?

The healthcare provider’s history and physical.

Recent urine drug testing (UDT) results

Baseline nursing admission assessment

Abnormal Involuntary Movement Scale (AIMS)

Answer and Explanation

The Correct Answer is D

A.   The healthcare provider's history and physical may provide information about the client's overall health but may not specifically address the observed symptoms.
B.   Recent urine drug testing (UDT) results may reveal drug use but may not be directly related to the observed involuntary movements.
C. The baseline nursing admission assessment may provide general information but may not specifically address medication side effects.
D.   The Abnormal Involuntary Movement Scale (AIMS) is specifically designed to assess and document involuntary movements associated with psychotropic medications, making it the most relevant assessment tool in this situation.

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Correct Answer is B

Explanation

A. While marijuana may not be considered highly addictive compared to some substances, the response should address the potential risks and consequences of marijuana use rather than focusing solely on addiction.
B. This response highlights the immediate concern of altering one's ability to think clearly, emphasizing potential risks to both the individual and others.
C. Healthcare providers prescribing marijuana for specific medical purposes does not directly address the student's concern about recreational use.
D. Discussing moral implications may be a subjective approach and may not provide concrete information about the potential risks associated with marijuana use.

A. Inform unlicensed assistive personnel (UAP) that the client will likely complain of a sore throat and fever. B. Place the client in protective isolation for the first two weeks of treatment with this medication. C. Offer this medication to the client with food to decrease the possibility of gastric upset. D. Report findings from the client’s weekly white blood cell (WBC) counts to the healthcare provider.

Correct Answer is D

Explanation

A. While sore throat and fever can be potential side effects of clozapine, informing UAP is not a proactive intervention. Regular monitoring of white blood cell (WBC) counts is crucial for
detecting clozapine-induced agranulocytosis.
B. Protective isolation is not a standard practice for clients taking clozapine. Monitoring for specific side effects, such as agranulocytosis, is more important.
C. Offering clozapine with food is not a priority intervention for managing potential side effects.
Monitoring and reporting WBC counts take precedence.
D. Clozapine is associated with the risk of agranulocytosis. Regular monitoring of WBC counts is essential, and any findings outside the normal range should be promptly reported to the
healthcare provider.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During a high school substance abuse class, a student tells the group, “I know that marijuana is not addicting, so why shouldn’t I use it? Which response is best for the nurse to provide?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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