A nurse is caring for a client who has a new prescription for risperidone. Which of the following rating scales should the nurse complete prior to administering the first dose of risperidone?
The Hamilton Depression Scale
The Body Attitude Test
The Abnormal Involuntary Movement Scale
The Recovery Attitude and Treatment Evaluator
The Correct Answer is C
Choice A reason: The Hamilton Depression Scale is used to assess severity of depression, not antipsychotic side effects.
Choice B reason: The Body Attitude Test is used in eating disorder assessments, unrelated to risperidone therapy.
Choice C reason: The Abnormal Involuntary Movement Scale (AIMS) evaluates for movement disorders like tardive dyskinesia, which are possible side effects of antipsychotics. Baseline assessment is essential before starting treatment.
Choice D reason: The Recovery Attitude and Treatment Evaluator measures patient attitudes about recovery and treatment, not medication side effects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This reflects an internal crisis of denial, where the client struggles to accept the diagnosis and cope with the emotional impact, leading to rejection of treatment.
Choice B reason: A situational crisis is triggered by external life events like loss of a job or sudden illness in a family member, not by denial of a personal diagnosis.
Choice C reason: A maturational crisis occurs during developmental transitions like adolescence or retirement, which is unrelated to this scenario.
Choice D reason: An adventitious crisis is caused by unexpected disasters such as natural catastrophes or acts of violence, not a medical diagnosis.
Correct Answer is A
Explanation
Choice A reason:Major depressive disorder carries a high risk of suicide, especially in acute settings. Monitoring for self-harm is the priority to ensure the client’s safety, as it addresses an immediate, life-threatening risk before other interventions.
Choice B reason:Administering antidepressants is important for managing depression, but it is not the priority over safety. Antidepressants take weeks to become effective, and the risk of self-harm must be addressed first.
Choice C reason:Assisting with activities of daily living supports the client’s functional needs, but it is not the priority. Safety concerns, such as self-harm risk, take precedence in acute depression.
Choice D reason:Encouraging fluid intake is important for physical health, but it is not the priority in major depressive disorder. Preventing self-harm is critical due to the high risk of suicide in this condition.
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