A nurse is caring for a client who has a dissociative disorder. Which of the following actions should the nurse take first?

Administer a benzodiazepine to the client.

Establish rapport with the client.

Teach the client grounding techniques.

Educate the client about their disorder.

Answer and Explanation

The Correct Answer is B

A. Administer a benzodiazepine to the client: While benzodiazepines may be useful for managing anxiety, the first step in caring for a client with a dissociative disorder is to build a trusting relationship. Medications should not be prioritized over establishing rapport.
B. Establish rapport with the client: Building rapport is crucial in creating a safe environment for the client. It allows the nurse to gain the client’s trust, facilitating effective communication and treatment. A strong therapeutic alliance is essential for the client's willingness to engage in further interventions.
C. Teach the client grounding techniques: While grounding techniques can be beneficial for clients experiencing dissociation, they are most effective when the client feels safe and supported. Establishing rapport first will help the client be more receptive to learning and practicing these techniques.
D. Educate the client about their disorder: Education is important, but it should come after establishing a trusting relationship. The client may not be open to education about their disorder until they feel comfortable with the nurse and the therapeutic process.

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Correct Answer is C

Explanation

A. Personality Diagnostic Questionnaire: This tool is specifically designed for assessing and diagnosing personality disorders, such as borderline or antisocial personality disorder. While it provides valuable insights into personality traits, it does not yield information on recent substance use and is not applicable for determining if the client has used illicit drugs.
B. Eysenck Personality Inventory: The Eysenck Personality Inventory focuses on measuring personality traits, particularly dimensions like introversion and extraversion. Although it may be useful in understanding the client's personality profile, it lacks the capability to assess or screen for substance use, making it irrelevant in this context.
C. Toxicology test: A toxicology test is the most appropriate screening tool in this situation as it directly analyzes the client’s biological samples (such as urine, blood, or saliva) to detect the presence of illicit substances. This test provides immediate and objective evidence of recent drug use, which is crucial for the nurse to make informed clinical decisions regarding the client's care and potential interventions.
D. Minnesota Multiphasic Personality Inventory (MMP): The MMPI is a comprehensive psychological assessment tool that evaluates various psychological conditions and personality traits. While it can provide insights into the client’s mental health, it does not specifically test for substance use, thus making it an unsuitable option for assessing recent illicit drug consumption.

A. Seizures and tremors B. Uncontrolled movements around the mouth C. Hallucinations and delusions D. Nausea and vomiting

Correct Answer is B

Explanation

A. Seizures and tremors: Seizures are not a typical adverse effect of tardive dyskinesia. Tremors can occur with other types of extrapyramidal symptoms (EPS) related to antipsychotic medications, but they are not specific to tardive dyskinesia.
B. Uncontrolled movements around the mouth: Tardive dyskinesia is characterized by involuntary, repetitive movements, often involving the mouth, face, and tongue. These movements can include lip smacking, grimacing, and tongue protrusion, making this option the most appropriate.
C. Hallucinations and delusions: These symptoms are associated with the primary mental illness (such as schizophrenia) rather than being direct adverse effects of tardive dyskinesia or antipsychotic medication. Tardive dyskinesia is a movement disorder, not a psychotic symptom.
D. Nausea and vomiting: Nausea and vomiting can be side effects of antipsychotic medications, particularly in the early phases of treatment or with certain medications. However, they are not specifically associated with tardive dyskinesia.

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A nurse is caring for a client who has a dissociative disorder. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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