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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
A. A relapse plan explains how you can be hospitalized if needed. A relapse plan focuses on early symptom recognition and intervention rather than hospitalization. While hospitalization may be necessary in severe cases, the primary goal is to prevent relapse through proactive measures.
B. A relapse plan addresses your living, housing, and working needs. While stable housing and employment are important for recovery, a relapse plan is specifically designed to identify early warning signs and strategies to prevent symptom exacerbation rather than addressing broader social needs.
C. A relapse plan describes how you use coping strategies for living in the community. While coping strategies are included, a relapse plan is more comprehensive, incorporating early symptom detection, medication adherence, and support systems to prevent deterioration.
D. A relapse plan helps your recovery by recognizing symptoms of schizophrenia and provides steps to follow if symptoms are getting worse. Recognizing early symptoms of schizophrenia and implementing preplanned interventions can reduce the likelihood of a full relapse, allowing for timely adjustments in treatment and support.
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