A nurse is caring for a client who has factitious disorder. The client states, "I am so tired of living like this. Maybe I should just end it all." Which of the following actions should the nurse take?

Assess the client for suicidal ideation and thoughts of self-harm.

Determine if the client has entered one of their alter personalities.

Encourage the client to use relaxation techniques.

Encourage the client to participate in group therapy sessions.

Answer and Explanation

The Correct Answer is A

A. Assess the client for suicidal ideation and thoughts of self-harm. The client's statement about feeling tired of living and contemplating ending it all indicates a potential risk for suicide. It is essential for the nurse to conduct a thorough assessment of the client’s mental state, including any suicidal thoughts or plans, to ensure their safety.
B. Determine if the client has entered one of their alter personalities. This action is not relevant to factitious disorder, as it involves intentionally producing or feigning symptoms rather than dissociative identity disorder, which features the presence of distinct personality states.
C. Encourage the client to use relaxation techniques. While relaxation techniques can be beneficial for managing stress, they do not address the immediate risk of suicidal ideation and should not be prioritized over a safety assessment.
D. Encourage the client to participate in group therapy sessions. While group therapy can be beneficial, it may not be appropriate to encourage participation until the client's safety is ensured. Assessing for suicidal thoughts takes precedence to address any immediate risk to the client.

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Correct Answer is D

Explanation

A. Nausea and vomiting. While some antipsychotic medications may cause gastrointestinal side effects, nausea and vomiting are not characteristic of tardive dyskinesia. Tardive dyskinesia specifically affects involuntary motor control.
B. Hallucinations and delusions. These are symptoms of psychotic disorders, not side effects of tardive dyskinesia. While some antipsychotic medications can cause paradoxical worsening of psychosis, tardive dyskinesia primarily involves involuntary movements rather than psychiatric symptoms.
C. Seizures and tremors. Some antipsychotics lower the seizure threshold, increasing seizure risk, while tremors are more associated with drug-induced parkinsonism. However, these are different from the repetitive, involuntary movements seen in tardive dyskinesia.
D. Uncontrolled movements around the mouth. Tardive dyskinesia is a serious side effect of long-term antipsychotic use, characterized by involuntary movements, especially around the mouth, tongue, and face (e.g., lip smacking, tongue protrusion, and grimacing). These movements can become permanent, making early detection and intervention crucial.

A. Review treatment goals that have been accomplished. B. Introduce the concept of discharge planning. C. Gather data about the client's home situation. D. Provide personal contact information to the client for use in case of emergency.

Correct Answer is A

Explanation

A. Review treatment goals that have been accomplished. In the termination phase of the nurse-client relationship, it is essential to evaluate and review the progress made towards the treatment goals. This helps reinforce the client's achievements and prepares them for future independence.
B. Introduce the concept of discharge planning. While discharge planning is important, it is typically discussed earlier in the nursing process rather than during the termination phase. By this point, the client should already be aware of their discharge plans.
C. Gather data about the client's home situation. This action is more appropriate during the initial assessment phase or when planning care, rather than during termination. The focus should be on reflecting on progress and preparing for discharge.
D. Provide personal contact information to the client for use in case of emergency. This is not appropriate in the termination phase, as it can blur professional boundaries and may not adhere to nursing ethical standards. Instead, referrals to appropriate resources should be provided.

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A nurse is caring for a client who has factitious disorder. The client states, "I am so tired of living like this. Maybe I should just end it all." Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a serious mental illness and has developed tardive dyskinesia from anti-psychotic medication use. Which of the following adverse effects from anti-psychotic medication use would be expected for the client?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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