A nurse is in the day room of an acute care mental health facility with a group of clients who are watching television.
Suddenly, one of the clients jumps up screaming and runs out of the room.
What should the nurse do next?
Ask the group what they think about the client’s behavior.
Stay with the group and ask another client to go and check on the situation.
Follow the client to determine the cause of the behavior.
Ignore the incident since it is an attention-seeking behavior.
The Correct Answer is C
Choice A rationale:
Asking the group what they think about the client's behavior is not appropriate for several reasons. It could violate the client's confidentiality, it could create a sense of judgment or stigma among the group members, and it is unlikely to provide accurate or helpful information about the cause of the behavior. The nurse's primary responsibility is to the client who is experiencing distress, not to gather opinions from others.
Choice B rationale:
Staying with the group and asking another client to check on the situation is also not appropriate. It is the nurse's responsibility to assess and address the client's behavior, not to delegate this task to another client. This could potentially put the other client at risk, as they may not have the training or skills to handle the situation effectively. Additionally, it could create a sense of division or lack of support within the group.
Choice D rationale:
Ignoring the incident is never appropriate, as it could potentially endanger the client or others. It is important to remember that all behaviors have meaning, and even attention-seeking behaviors can be a sign of underlying distress. The nurse needs to assess the situation to determine the cause of the behavior and provide appropriate interventions.
Choice C rationale:
Following the client to determine the cause of the behavior is the most appropriate action for the nurse to take. This allows the nurse to assess the client's safety, provide support, and intervene as necessary. It also demonstrates to the client that the nurse is concerned and willing to help. Key considerations for the nurse:
Safety: The nurse's primary concern is always the safety of the client, themselves, and others. It's crucial to assess for any potential risks of harm and take appropriate precautions.
Assessment: Careful observation and assessment of the client's behavior, including verbal and nonverbal cues, can provide valuable insights into the underlying causes.
Communication: Establishing a calm, supportive, and non-judgmental communication with the client is essential to gain their trust and cooperation.
Intervention: The nurse may need to employ various interventions, such as de-escalation techniques, distraction, or medication, depending on the assessment and the client's needs.
Documentation: Thorough documentation of the incident, the nurse's assessment, and interventions is important for continuity of care and communication with other healthcare professionals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
While group activities can be beneficial for some clients with bipolar disorder, they may not be appropriate during a manic phase. This is because group settings can be overstimulating and overwhelming for individuals experiencing mania. The increased activity and social interaction can exacerbate symptoms such as racing thoughts, pressured speech, and impulsivity.
It's crucial to prioritize calming activities and minimize external stimuli during manic episodes.
Choice C rationale:
Providing a stimulating environment is not recommended for clients in the manic phase of bipolar disorder. A stimulating environment can worsen symptoms of mania, such as:
Increased energy and activity levels
Racing thoughts
Impulsivity
Distractibility
Risk-taking behavior
Irritability
Aggression
Decreased need for sleep Grandiose thinking
Poor judgment
Hypersexuality
A calm and structured environment is more conducive to managing manic symptoms.
Choice D rationale:
Scheduling daily seclusion times is not a standard intervention for clients in the manic phase of bipolar disorder. Seclusion is a restrictive intervention that should only be used as a last resort when a client is at risk of harming themselves or others. It's essential to explore less restrictive alternatives for managing manic symptoms, such as medication, therapy, and environmental modifications.
Correct Answer is A
Explanation
Choice A rationale:
Pseudoparkinsonism is an extrapyramidal side effect (EPSE) of antipsychotic medications, particularly first-generation antipsychotics (FGAs) like haloperidol, that closely resembles the symptoms of Parkinson's disease. It's characterized by:
Stooped posture: A forward-leaning posture, often with rounded shoulders and a head that is bent forward.
Shuffling gait: Small, slow steps with reduced arm swing, often described as a "shuffling" or "dragging" walk.
Rigidity: Increased muscle stiffness throughout the body, leading to resistance to movement and a feeling of tightness.
Bradykinesia: Slowness of movement, both in initiating and completing actions.
Tremor: Involuntary shaking, often most noticeable in the hands, but can also affect the arms, legs, head, or jaw.
Masked facies: A decreased facial expression, often described as a "flat" or "expressionless" face.
Mechanism of pseudoparkinsonism:
Haloperidol primarily blocks dopamine D2 receptors in the nigrostriatal pathway of the brain.
Dopamine plays a crucial role in motor control, and its blockade in this pathway leads to a disruption in the balance of dopamine and acetylcholine, another neurotransmitter involved in movement.
This imbalance results in the characteristic symptoms of pseudoparkinsonism.
Risk factors for pseudoparkinsonism:
Older age
Female sex
Higher doses of antipsychotic medication
Prolonged use of antipsychotic medication
History of Parkinson's disease or other movement disorders
Presence of other EPSEs
Management of pseudoparkinsonism:
Dose reduction: If possible, the dose of the antipsychotic medication may be reduced.
Switching to a different antipsychotic: Some antipsychotics, such as second-generation antipsychotics (SGAs), have a lower risk of causing EPSEs.
Anticholinergic medications: These medications can help to counteract the effects of dopamine blockade on the acetylcholine system, but they can have their own side effects, such as dry mouth, constipation, and urinary retention.
Amantadine: This medication can also be used to treat pseudoparkinsonism, but it has the potential to cause side effects such as insomnia, anxiety, and livedo reticularis (a mottled skin rash).
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.