A nurse is caring for a client who has delusional behavior. The client states, "I can't go to group today. I am expecting a high level official to visit me!" Which of the following responses should the nurse make?

"Let's walk together to group so we can discuss your concerns."

"I think you should attend group therapy. We will talk about this when you're done."

"I wouldn't worry about that. They will call you back later."

"Why do you think you are getting a visit from someone today?"

Answer and Explanation

The Correct Answer is A

A.   Acknowledge the client’s delusion while gently redirecting them to the necessary activity (group
therapy). This approach maintains engagement without directly confronting the delusion.
B.   Ignoring the delusion and focusing only on group therapy may cause the client to feel unheard or dismissed.
C.   Dismissing the delusion is not therapeutic and could undermine trust.
D.   Asking "why" could challenge the delusion, leading to defensiveness rather than productive conversation.

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Correct Answer is A

Explanation

A. The nurse’s primary concern is preventing the client from embarrassing herself due to the impulsive and disinhibited behaviors typical of a manic episode.
B. There is no indication that dancing is prohibited; the issue is with inappropriate behavior.
C. The focus of the action is not on sexual behavior but on ensuring the client is appropriately dressed in a social setting.
D. Following policy is important, but the nurse’s action is more about protecting the client from social
embarrassment.

A. Impaired gait B. Fidgeting behavior C. Muscle contractions of the neck D. Fluctuating vital signs E. Sexual dysfunction

Correct Answer is ["A","C"]

Explanation

A. Impaired gait is a classic extrapyramidal symptom, which includes issues like dystonia or bradykinesia.
B. Fidgeting behavior is more related to anxiety or restlessness rather than EPS.
C. Muscle contractions of the neck, known as torticollis, are common signs of EPS caused by antipsychotic medications such as chlorpromazine.
D. Fluctuating vital signs are not directly linked to EPS but may indicate another underlying issue.
E. Sexual dysfunction is a side effect of chlorpromazine but not classified as an EPS.

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A nurse is caring for a client who has delusional behavior. The client states, "I can't go to group today. I am expecting a high level official to visit me!" Which of the following responses should the nurse make?

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Correct Answer is A

Explanation

A nurse is collecting data from a client who is taking chlorpromazine. Which of the following findings should the nurse identify as extrapyramidal symptoms (EPS)? (Select all that apply.)

Correct Answer is ["A","C"]

Explanation

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