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.

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Correct Answer is C

Explanation

A. "This medication may increase your blood pressure."

This statement is incorrect. Risperidone is not typically associated with significant increases in blood pressure. One of the potential side effects of risperidone is orthostatic hypotension, which is a drop in blood pressure when changing positions (e.g., standing up quickly). Therefore, this choice is not the best instruction to include in the teaching.

B. "Flu-like symptoms are an expected adverse effect of this medication."

This statement is incorrect. While risperidone can have side effects, flu-like symptoms are not commonly associated with it. Common side effects of risperidone may include dizziness, drowsiness, weight gain, and movement disorders. Flu-like symptoms are not a typical adverse effect of this medication.

C. "Avoid becoming overheated while taking this medication."

This statement is correct. Risperidone, like many other antipsychotic medications, can interfere with the body's ability to regulate temperature. This can lead to an increased risk of overheating, especially in hot weather or during vigorous physical activity. Therefore, it's important for patients taking risperidone to be cautious and avoid becoming overheated, as this could potentially lead to heat-related complications.

D. "Muscle twitches can occur the first few weeks while taking this medication."

This statement is incorrect. Muscle twitches are not a common side effect of risperidone. While it's true that some movement disorders can occur with antipsychotic medications, the statement is too specific to muscle twitches and does not accurately reflect the typical side effect profile of risperidone.

A. Attention-seeking conduct B. Wild fidgeting C. Threatening behavior D. Mild difficulty problem solving

Correct Answer is B

Explanation

A.In the context of severe anxiety, clients might engage in attention-seeking behaviors as a way to express their distress or seek support. However, wild fidgeting remains a more direct and common manifestation of severe anxiety.

B.Severe anxiety can lead to various physical and psychological manifestations. "Wild fidgeting" is a common physical manifestation of severe anxiety. It involves restlessness, rapid movements, and an inability to sit still. Fidgeting can be a way for individuals to release excess energy and manage their heightened anxiety levels.

C.While severe anxiety can lead to a variety of behaviors, threatening behavior is not a typical or direct manifestation of severe anxiety. Such behavior may be more indicative of other mental health issues or agitation.

D.Severe anxiety is more likely to cause impairments in concentration, focus, and problem-solving abilities rather than mild difficulty. Severe anxiety can lead to cognitive overload and make it challenging for individuals to think clearly and solve problems effectively.

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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

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Explanation

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Explanation

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