A nurse is caring for a client in an outpatient clinic.

Exhibits

Select the 3 interventions the nurse should plan to take.

Encourage the client to think positive thoughts.

Assist the client in distinguishing between anxiety and physical manifestations.

Provide relief measures for manifestations the client is experiencing.

Inform the client that nothing is medically wrong with them.

Suggest to the client's provider that multiple tests need to be performed.

Perform a lengthy exam of client's condition.

Answer and Explanation

Correct Answer : B,C,E

A. Encourage the client to think positive thoughts. While promoting positive thinking can be helpful, this approach may oversimplify the client's experience and does not address their anxiety or physical symptoms effectively.
B. Assist the client in distinguishing between anxiety and physical manifestations. This intervention is crucial as it helps the client understand the connection between their anxiety and physical symptoms. It can empower the client to better manage their feelings and reduce their fixation on health issues.
C. Provide relief measures for manifestations the client is experiencing. Addressing the client's physical symptoms, such as anxiety and stomach discomfort, is important for their overall well-being and can improve their quality of life.
D. Inform the client that nothing is medically wrong with them. This statement may dismiss the client's concerns and could lead to feelings of frustration or invalidation. It is important to listen to the client’s experiences without minimizing them.
E. Suggest to the client's provider that multiple tests need to be performed. Given the client's report of ongoing symptoms and concerns about their health, it is appropriate to recommend further evaluation to rule out any underlying medical issues. This ensures that the client feels heard and their concerns are taken seriously.
F. Perform a lengthy exam of the client's condition. Conducting a lengthy exam may not be necessary at this stage, especially in an outpatient setting. Instead, focusing on understanding the client's experience and addressing their concerns is more beneficial.

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Correct Answer is D

Explanation

A. Shuffling walk. A shuffling walk is typically associated with parkinsonism or other movement disorders, which may occur with antipsychotic medications, but the specific symptom of restlessness more directly relates to other conditions.
B. Suicidal ideation. While monitoring for suicidal ideation is important in any client with psychosis, it is not specifically associated with the restlessness that the client reports in relation to chlorpromazine use.
C. Abnormal movements of the tongue and face. Abnormal movements of the tongue and face are more characteristic of tardive dyskinesia, which develops over a longer period of treatment. The acute restlessness the client is experiencing is more closely aligned with akathisia, a side effect of antipsychotic medications.
D. Oculogyric crisis. This condition involves involuntary upward eye movement and can occur as an acute dystonic reaction to antipsychotic medications like chlorpromazine. Given the client's report of restlessness, the nurse should monitor for this adverse effect, as it is more likely to manifest in the context of acute medication side effects.

A. A history of self-injurious behavior B. A history of schizophrenia C. Borderline personality disorder D. History of trauma during the developmental years

Correct Answer is D

Explanation

A. A history of self-injurious behavior. While self-injurious behavior can be associated with various mental health conditions, it is not specifically identified as a risk factor for dissociative identity disorder (DID).
B. A history of schizophrenia. Schizophrenia is a distinct mental health disorder characterized by psychotic symptoms, and while individuals with schizophrenia may experience dissociation, it is not considered a direct risk factor for DID.
C. Borderline personality disorder. While there is some overlap between symptoms of borderline personality disorder and dissociative symptoms, having borderline personality disorder itself is not a primary risk factor for developing DID.
D. History of trauma during the developmental years. A significant risk factor for dissociative identity disorder is a history of severe trauma or abuse during childhood, particularly chronic emotional, physical, or sexual abuse. This trauma can disrupt normal psychological development and contribute to the fragmentation of identity characteristic of DID.

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A nurse is caring for a client in an outpatient clinic. Exhibits Select the 3 interventions the nurse should plan to take.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has psychosis and is prescribed chlorpromazine. The client reports feelings of restlessness. The nurse should identify that the client should be monitored for which of the following adverse effects?

Correct Answer is D

Explanation

A nurse is preparing an in-service for a group of staff members about dissociative identity disorder. Which of the following should the nurse identify as a risk factor for this disorder?

Correct Answer is D

Explanation

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A nurse is caring for a client in an outpatient clinic.

Exhibits

Select the 3 interventions the nurse should plan to take.