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 D

Explanation

A. Asking the client to describe and identify feelings is more appropriate for a client with mild to moderate anxiety, not severe anxiety.
B. Providing education is ineffective during severe anxiety because the client is unable to process new information.
C. Relaxation techniques are difficult for a client to use during severe anxiety due to impaired concentration and focus.
D. Reducing environmental stimuli by escorting the client from the group is the best intervention for severe anxiety, as it helps the client regain control and lowers anxiety levels.

A. Blood pressure. B. Urinary output. C. Respiratory rate. D. Temperature.

Correct Answer is A

Explanation

Rationale:
A. MAO inhibitors such as phenelzine can cause significant fluctuations in blood pressure, including hypertensive crisis when combined with certain foods or medications. Therefore, monitoring blood pressure is crucial to detect and prevent hypertensive emergencies.
B. While monitoring urinary output is important for overall assessment, it is not specifically associated with the use of MAO inhibitors like phenelzine.
C. Respiratory rate is not typically affected by MAO inhibitors like phenelzine and may not be the most relevant assessment finding in this scenario.
D. Temperature monitoring is important for general assessment but is not specifically associated with the use of MAO inhibitors like phenelzine.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

Correct Answer is D

Explanation

In conducting the initial assessment of a preoperative client, the nurse notes that the client's home medications include the monoamine oxidase (MAO) inhibitor phenelzine. Because of this client's medication history, which assessment finding is most important for the nurse to monitor?

Correct Answer is A

Explanation

A client with a history of alcoholism is admitted for detoxification. Based on treatment protocol, the nurse gives the client a dose of lorazepam 6 mg. Which additional prescription should the nurse administer immediately?

Which intervention(s) should the nurse include in the plan of care for an adolescent client who is depressed? Select all that apply.

A male client with a recent diagnosis of bipolar disorder takes lithium carbonate daily. The client informed the school nurse of the desire to live away from home to attend college after graduating in one month. Which information is most important for the nurse to provide the client and his family?

The nurse wants to teach the client about the long-term phase symptoms of rape-trauma syndrome. What symptoms are consistent with long-term rape trauma? Select all that apply.

When the nurse addresses questions to an adult client who is depressed, the client's responses are delayed. Which intervention should the nurse include in the client's plan of care?

A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease related?

A client is admitted to the mental health unit with a bipolar disorder. When seeking to establish a therapeutic relationship and interacting with the client, which comment is best for the nurse to make?