A nurse in a mental health facility is reinforcing teaching to a newly licensed nurse about how to perform an Abnormal Involuntary Movement Scale (AIMS) test on a client. The charge nurse should identify that the AIMS test is used for which of the following conditions?

Lithium toxicity

Alcohol withdrawal

Tardive dyskinesia

Opiate withdrawal

Answer and Explanation

The Correct Answer is C

A. Lithium toxicity. The AIMS test does not assess lithium toxicity. Lithium toxicity is monitored through serum lithium levels and clinical symptoms such as tremors, nausea, confusion, and ataxia. Severe toxicity can lead to seizures, coma, and organ failure, requiring immediate intervention.
B. Alcohol withdrawal. The AIMS test does not assess alcohol withdrawal. Withdrawal symptoms include tremors, hallucinations, seizures, and autonomic instability. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is commonly used to assess symptom severity and guide treatment.
C. Tardive dyskinesia. The AIMS test is used to assess tardive dyskinesia, a movement disorder caused by long-term antipsychotic use. It evaluates involuntary movements of the face, tongue, and extremities, helping clinicians monitor progression and adjust medications to minimize symptoms.
D. Opiate withdrawal. The AIMS test does not assess opiate withdrawal. Symptoms include sweating, agitation, diarrhea, and muscle aches. The Clinical Opiate Withdrawal Scale (COWS) is typically used to assess withdrawal severity and guide opioid detoxification or replacement therapy.

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Correct Answer is D

Explanation

A. Fluoxetine. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used to treat depression, anxiety, and obsessive-compulsive disorder. It does not alleviate tardive dyskinesia symptoms and is not indicated for managing extrapyramidal side effects.
B. Diphenhydramine. Diphenhydramine is an antihistamine that can help with acute dystonic reactions due to its anticholinergic effects, but it does not treat tardive dyskinesia. Long-term use may even worsen movement disorders.
C. Naloxone. Naloxone is an opioid antagonist used to reverse opioid overdose. It has no effect on tardive dyskinesia, as this condition is related to prolonged dopamine receptor blockade rather than opioid activity.
D. Valbenazine. Valbenazine is a vesicular monoamine transporter 2 (VMAT2) inhibitor specifically approved for the treatment of tardive dyskinesia. It helps regulate dopamine release and reduces involuntary movements associated with the condition.

A. Tell the client that there is nothing there. B. Ask the client to describe what is being seen. C. Touch the client's arm reassuringly. D. Remove the client from the room.

Correct Answer is B

Explanation

A. Tell the client that there is nothing there. Dismissing the client's perception may increase distress and reduce trust in the nurse-client relationship. A therapeutic approach acknowledges the client’s experience without reinforcing or denying hallucinations.
B. Ask the client to describe what is being seen. Encouraging the client to describe the hallucination helps assess its nature and severity. Understanding the content allows the nurse to provide appropriate support, ensure safety, and guide interventions.
C. Touch the client's arm reassuringly. Touching the client without consent, especially during a distressing hallucination, may escalate fear or agitation. Maintaining a calm and non-threatening presence is more appropriate.
D. Remove the client from the room. Relocating the client without assessing the hallucination may not address the underlying distress. Identifying triggers and using therapeutic communication are more effective initial interventions.

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A nurse in a mental health facility is reinforcing teaching to a newly licensed nurse about how to perform an Abnormal Involuntary Movement Scale (AIMS) test on a client. The charge nurse should identify that the AIMS test is used for which of the following conditions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is taking fluphenazine and is experiencing tardive dyskinesia. Which of the following medications should the nurse anticipate the provider to prescribe for this client?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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