A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone. When the client walks to the nurse's station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the nurse take?

Administer the prescribed anticholinergic benztropine for dystonia.

Offer the client a prescribed physical therapy hot pack for muscle spasms.

Direct the client to occupational therapy to distract him from somatic complaints.

Medicate the client with the prescribed antipsychotic thioridazine.

Answer and Explanation

The Correct Answer is A

A.   The client's symptoms, including a laterally contracted position and perception of body contortion, suggest acute dystonia, a known side effect of antipsychotic medications like risperidone. Administering an anticholinergic such as benztropine can help alleviate these symptoms.
B.   Offering a hot pack for muscle spasms may provide some relief for generalized muscle discomfort but would not specifically address the dystonic reaction.
C.   Directing the client to occupational therapy may be beneficial for overall treatment but does not address the immediate need to alleviate acute dystonic symptoms.
D.   Thioridazine is an antipsychotic medication but is not typically used as a first-line treatment for acute dystonia. Administering benztropine, an anticholinergic, would be more appropriate for dystonia associated with risperidone use.

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Correct Answer is B

Explanation

- Choice A Rationale: Determining the type and size of the locks does not address the client's anxiety or the behavior that is impacting their daily functioning. This action might inadvertently reinforce the client's focus on the locks rather than addressing the underlying issue.
- Choice B Rationale: Planning a list of activities to be carried out daily can help the client establish a routine, which may reduce anxiety and the need for repetitive checking. This approach encourages the client to focus on the day's tasks and can provide a sense of control and accomplishment.
- Choice C Rationale: Discussing checking the time frequently does not directly address the client's repetitive behavior or the associated anxiety. While time management may be part of a broader treatment plan, it is not the most immediate action the nurse should take.
- Choice D Rationale: Ask the client why the locks are checked so frequently is not therapeutic and may put the client on the defensive. Clients with obsessive-compulsive behaviors often cannot explain why they perform rituals, as the behavior is driven by anxiety rather than logic. Asking "why" may increase frustration without helping to address the behavior.

A. Establish trust by providing a calm, safe environment. B. Encourage deep breathing when anxiety escalates in a crowd. C. Progressively expose the client to larger crowds. D. Encourage substitution of positive thoughts for negative ones.

Correct Answer is A

Explanation

A. Establishing trust by providing a calm, safe environment is crucial for clients with agoraphobia, as it lays the foundation for effective therapeutic interventions and supports the client's sense of safety and security.
B. Encouraging deep breathing is a helpful coping strategy, but it may not be the highest priority compared to establishing trust and safety.
C. Progressively exposing the client to larger crowds is part of desensitization therapy, but it should be done gradually and only after trust and rapport have been established.
D. Encouraging substitution of positive thoughts for negative ones is a valuable cognitivebehavioral technique, but it may be more effective once the client feels safe and supported in the therapeutic environment.

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Naxlex Comprehensive Predictor Exams

A client engages in repeated checks of door and window locks and behavior that prevents the client from arriving on time and interfering with the ability to function effectively. Which action should the nurse take?

Correct Answer is B

Explanation

A client who has agoraphobia is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?

Correct Answer is A

Explanation

The nurse is performing the admission assessment for a client with schizophrenia in an acute care inpatient facility. The nurse should identify which observed behavior is characteristic of schizophrenia?

The nurse is admitting a male client who takes lithium carbonate twice a day. Which information should the nurse report to the healthcare provider immediately?

The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in depth with the client based on this screening tool?

The nurse has received a new prescription for the client to begin taking sertraline. Prior to administering the initial dose of sertraline, it is most important for the nurse to obtain which information?

A client requests permission for the spouse to remain in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client's verbal and nonverbal communication. Which action should the nurse take?

A client who is an alcoholic receives a prescription for disulfiram 500 mg by mouth (PO) daily. Which instruction should the nurse provide to this client?