When assessing a female client who has been taking an antipsychotic medication for the past year, the nurse observes that the client demonstrates involuntary foot tapping while both feet are flat on the floor. The nurse plans to report the observation to the healthcare provider. Which additional action should the nurse take?

Document the finding on the Abnormal Involuntary Movement Scale.

Assist the client in recognizing her manifestations of anxiety.

Prepare to initiate seizure precautions for the client's safety.

Advise the client that she has developed tolerance to the medication

Answer and Explanation

The Correct Answer is A

Choice A rationale: Documenting the finding on the Abnormal Involuntary Movement Scale (AIMS) is appropriate. The AIMS is a standardized tool used to assess and document abnormal movements associated with antipsychotic medications, such as tardive dyskinesia.

Choice B rationale: Assisting the client in recognizing her manifestations of anxiety is unrelated to the observed foot tapping and does not address the potential side effects of antipsychotic medication.

Choice C rationale: Preparing to initiate seizure precautions for the client's safety is not indicated based on the observed foot tapping. Seizure precautions are not typically associated with antipsychotic medication side effects.

Choice D rationale: Advising the client that she has developed tolerance to the medication is speculative and not supported by the information provided. The observed foot tapping may be indicative of extrapyramidal side effects rather than tolerance.

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Correct Answer is A

Explanation

Choice A rationale: Altruism involves addressing one's own needs through meeting the needs of others, and caring for the husband's aging parents is an example of this coping mechanism.

Choice B rationale: Regression involves reverting to an earlier stage of development, which is not evident in the scenario.

Choice C rationale: Compartmentalization is the defense mechanism of separating conflicting thoughts or feelings, which is not clearly identified in the scenario. Choice D rationale: Egocentrism involves seeing the world from only one's own perspective, which is not the primary issue in the scenario.

A. If your partner is abusing you, I need to ask these questions. B. The healthcare provider needs to know if you are experiencing any domestic abuse. C. All clients are screened for domestic abuse because it is common in our society. D. State law mandates that I ask if you are a victim of domestic violence.

Correct Answer is C

Explanation

Choice A rationale: "If your partner is abusing you, I need to ask these questions" may be too direct and could potentially make the client feel pressured or uncomfortable. The nurse should emphasize the routine nature of the screening.

Choice B rationale: "The healthcare provider needs to know if you are experiencing any domestic abuse" is correct but may sound directive. Emphasizing the routine nature of the screening helps to normalize the process.

Choice C rationale: "All clients are screened for domestic abuse because it is common in our society" is the best choice. It normalizes the screening process, reducing stigma and encouraging disclosure.

Choice D rationale: "State law mandates that I ask if you are a victim of domestic violence" may make the client feel compelled to answer due to legal reasons, potentially affecting the validity of the response. Emphasizing routine screening is a more patient centered approach.

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Naxlex Comprehensive Predictor Exams

A woman who attends a stress management group reveals to group members that though she recently divorced, she continues to care for her husband's aging parents. Which psychological mechanism should the nurse address in the plan of care?

Correct Answer is A

Explanation

When preparing to administer a domestic violence screening tool to a female client, which statement should the nurse provide?

Correct Answer is C

Explanation

A client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because of a stalker. Which action is most important for the nurse to take?

A young woman is preparing to be discharged from the psychiatric unit. Which nursing intervention is most important for the nurse to Include in this phase of the nurse-client relationship?

A young adult client is admitted to a psychiatric facility with a diagnosis of bulimia nervosa. Which nursing intervention has the highest priority?

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An 18-year-old client is brought to the emergency department with a suspected drug overdose. Which information is most important for the nurse to obtain from the family?