A client is noted to be pacing on the unit with their hands clenched and mumbling curses. The nurse knows that the initial approach to this client would be to:

stop the client in the hall and tell them that they must pace in the day room instead.

keep hands in pockets so as not to appear threatening.

speak softly and calmly,

offer the client a cup of coffee.

Answer and Explanation

The Correct Answer is C

a. Stop the client in the hall and tell them that they must pace in the day room instead. This can be confrontational and might escalate the situation.
b. Keep hands in pockets so as not to appear threatening. While non-threatening body language is important, the focus should be on verbal communication.
c. Speak softly and calmly. De-escalation is key in such situations. A calm and non-threatening approach is essential to build rapport and assess the situation.
d. Offer the client a cup of coffee. Stimulants like caffeine might worsen anxiety.

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Correct Answer is C

Explanation

a. Administer the 6mg Benztropine orally with a full glass of water on an empty stomach: Benztropine is an anticholinergic medication used to manage the extrapyramidal side effects (EPS) of antipsychotics. However, it's important to consult the healthcare provider before administering any additional medications.
b. Ask the healthcare provider to increase the dose of Haloperidol to assist with the side effect: Increasing the dose of Haloperidol might worsen the tardive dyskinesia symptoms.
c. Hold the dose of Haloperidol and notify the healthcare provider. (Correct) Haloperidol is an antipsychotic medication with a known side effect of tardive dyskinesia, which manifests as involuntary facial and body movements. Stopping the medication and informing the provider is crucial to determine the best course of action, which might involve dose adjustment or switching medications

d. Explain to the client that the side effects should diminish in one to two weeks: Tardive dyskinesia can be a persistent side effect, and reassurance without addressing the medication is not helpful.

A. "I'm afraid you would feel very guilty leaving your parents." B. "Why would you want to leave a secure home?" C. "It would be best to do that to increase independence." D. "Let's discuss and explore all of your options.

Correct Answer is D

Explanation

a. "I'm afraid you would feel very guilty leaving your parents." This response assumes a negative outcome and does not encourage independent decision-making.
b. "Why would you want to leave a secure home?" This response discourages the client from considering independence and reinforces dependent behavior.
c. "It would be best to do that to increase independence." This statement provides advice rather than encouraging the client to explore their own feelings and options.
d. "Let's discuss and explore all of your options." This is correct because it encourages the client to consider various possibilities and promotes independent decision-making, which is essential for someone with dependent behaviors.

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A client is noted to be pacing on the unit with their hands clenched and mumbling curses. The nurse knows that the initial approach to this client would be to:

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a client diagnosed with schizophrenia, who has been prescribed Haloperidol for the past year. On assessment, the nurse notices that the client is demonstrating bizarre facial and tongue movements. What is the priority nursing intervention?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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