A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take?

Remain with the client.

Give to client a PRN sleeping medication,

Encourage the client to go back to bed.

Explore alternatives to pacing the floor with the client.

Answer and Explanation

The Correct Answer is A

Remaining with the client provides support and ensures their safety. The client's behavior indicates distress, and having a nurse nearby can help the client feel more comfortable and secure.

B. Give the client a PRN sleeping medication:

Explanation: Administering a sleeping medication should not be the first response, especially if the client is agitated. It's important to address the underlying cause of the agitation and consider other interventions before resorting to medication.

C. Encourage the client to go back to bed:

Explanation: Encouraging the client to go back to bed might not be effective if they are experiencing significant distress or anxiety. It's better to address their emotional state first before suggesting any changes in activity.

D. Explore alternatives to pacing the floor with the client:

Explanation: This is a reasonable course of action. Exploring alternatives to the client's current behavior can help address their distress and find ways to manage their emotions more effectively.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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

Explanation

Fine hand tremors and pill rolling are not indicative of tardive dyskinesia. These symptoms are more commonly associated with other neurological or movement disorders.

B. Urinary retention and constipation:

Urinary retention and constipation are not symptoms of tardive dyskinesia. These symptoms are more related to anticholinergic effects of certain medications.

C. Facial grimacing and eye blinking:

Facial grimacing and repetitive, involuntary movements such as eye blinking are characteristic of tardive dyskinesia. These abnormal movements of the face and eyes are commonly seen in individuals who have been on long-term antipsychotic medications, especially older ones like haloperidol.

D. Involuntary pelvic rocking and hip thrusting movements:

Involuntary pelvic rocking and hip thrusting movements are not typical symptoms of tardive dyskinesia. These types of movements are less associated with antipsychotic-induced movement disorders.

E. Tongue thrusting and lip-smacking:

Tongue thrusting and lip-smacking are classic symptoms of tardive dyskinesia. These repetitive, involuntary movements involving the mouth and tongue are often observed in individuals who have been on antipsychotic medications for an extended period of time.

A. Disclose some personal information to the client to demonstrate approachability. B. Approach the client frequently throughout the day for brief interactions. C. Adopt a neutral attitude when providing care. D. Wait for the client to initiate interaction.

Correct Answer is C

Explanation

Sharing personal information can blur the professional boundaries and might not be effective in reducing the client's suspicion. It's important to maintain a professional demeanor while building trust.

B) Approach the client frequently throughout the day for brief interactions:

While it's important to establish a presence and provide support, approaching the client too frequently might increase their discomfort and reinforce their suspicion. It's better to allow the client some personal space while ensuring they know you are available when needed.

C) Adopt a neutral attitude when providing care.

Explanation:

When dealing with a client who is extremely suspicious, it's important for the nurse to approach the situation with a neutral attitude. A neutral attitude helps to build trust and minimize any potential triggers for the client's suspicion. This approach creates a non-threatening environment where the client may feel more comfortable and gradually begin to open up.

D) Wait for the client to initiate interaction:

While giving the client space is important, waiting for them to initiate interaction might prolong the development of a therapeutic relationship. Clients who are extremely suspicious might have difficulty initiating interactions due to their concerns.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? (Select all that apply.)

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

Explanation

A nurse is Caring for a client who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client?

Correct Answer is C

Explanation

A nurse in a psychiatric unit is admitting a client who attacked a neighbor. The nurse should know that the client can be kept in the hospital after the 72-hr hold is ever for which of the following conditions?

A nurse is preparing to administer clozapine 300 mg PO daily to a client who has schizophrenia. The amount available is clozapine 200 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.l

A client who has major depressive disorder states to the nurse that he and his family would be better off if he were gone. Which of the following is the nurse's priority response?

A nurse is teaching a client who has depression about a new prescription for fluoxetine 20 mg daily. Which of the following statements by the clients understanding of the teaching?

A nurse is caring for a hospitalized client who tells lies about other clients. The other clients on the unit frequently complain to the nursing staff about the client's disruptive behaviors. Which of the following initial actions should the nurse take?

A nurse is caring for a client who has cancer and is scheduled for immediate chemotherapy. The client tells the nurse that she wants to try nontraditional treatments first. Which of the following responses should the nurse make?

A nurse is teaching a client who has a new prescription for chlorpromazine. Which of the following client statements indicates an understanding of the teaching?