A nurse is assisting with the care of a client who is admitted to the medical surgical unit.

Complete the following sentences by using the list of options:

The nurse anticipates the client will likely require

______

as evidenced by the client’s

_______

and

______

.

A) Completely undress the toddler:
Completely undressing a toddler can cause unnecessary distress and anxiety, especially if they are not prepared for the examination. It’s more appropriate to undress the toddler only as needed for the physical exam and allow them to remain clothed or partially clothed whenever possible to help them feel secure.

B) Allow the toddler to handle the equipment:
Allowing a toddler to handle the medical equipment is an excellent way to reduce fear and anxiety. This familiarizes the child with the instruments and allows them to feel more in control of the situation. It also helps in building trust with the nurse, making the examination less intimidating for the toddler.

C) Start the examination with routine immunizations:
Immunizations can be particularly stressful for toddlers, so starting the examination with vaccines is not the best approach. It’s better to begin with non-invasive procedures, such as listening to the heart or measuring the toddler’s height and weight, to build rapport before proceeding to any painful procedures.

D) Thoroughly explain each procedure to the toddler:
While it’s important to explain the examination to the toddler in simple, age-appropriate language, toddlers typically have a limited understanding of detailed explanations. Over-explaining may increase anxiety. Instead, it's better to keep things brief and comforting, using simple phrases, and focus on creating a positive experience.

A) Patient Health Questionnaire - 9:
The Patient Health Questionnaire-9 (PHQ-9) is a screening tool used to assess the severity of depression in a client. It is not specific to detecting tardive dyskinesia, which is a movement disorder caused by long-term use of antipsychotic medications. Therefore, this tool is not appropriate for assessing tardive dyskinesia.

B) Abnormal Involuntary Movement Scale:
The Abnormal Involuntary Movement Scale (AIMS) is the correct tool to screen for tardive dyskinesia. It is specifically designed to assess involuntary movements, such as those seen in tardive dyskinesia, which is a common side effect of long-term use of antipsychotic medications. The AIMS evaluates the presence and severity of abnormal movements, making it the most appropriate tool for this purpose.

C) Mental Status Examination:
The Mental Status Examination (MSE) is a broad assessment used to evaluate a client’s cognitive and emotional functioning. It includes aspects such as appearance, behavior, mood, thoughts, and perception but does not specifically assess for movement disorders like tardive dyskinesia. While it can provide useful information about a client's mental state, it is not focused on detecting motor side effects of antipsychotic medications.

D) Brief Psychiatric Rating Scale:
The Brief Psychiatric Rating Scale (BPRS) is used to assess the severity of psychiatric symptoms, including delusions, hallucinations, and mood disturbances, primarily in individuals with schizophrenia or other psychiatric disorders. It does not specifically assess for tardive dyskinesia, so it is not the most appropriate screening tool for identifying this condition.