A nurse on a mental health unit is assisting with the care of a client.
The nurse is continuing to assist with the care of the client. Select the four actions the nurse should take.
Ask the provider for a PRN prescription for restraints.
Administer diazepam when the client exhibits anxiousness.
Place the client in a room near the nurse's station.
Determine if the client is experiencing command hallucinations.
Establish clear limits for expected behaviors.
Correct Answer : B,C,D,E
A. Ask the provider for a PRN prescription for restraints: Restraints should only be used as a last resort when there is an imminent risk of harm to the client or others. In this situation, it is essential to first attempt to manage the client's anxiety and behavior through de-escalation strategies and appropriate interventions.
B. Administer diazepam when the client exhibits anxiousness: Diazepam can help manage anxiety and agitation, which is crucial for the client's safety and comfort. Monitoring for signs of anxiety allows for timely intervention with the prescribed medication.
C. Place the client in a room near the nurse's station: Keeping the client close to the nurse's station allows for increased monitoring and ensures that staff can respond quickly if the client's behavior escalates. This helps maintain safety for both the client and others on the unit.
D. Determine if the client is experiencing command hallucinations: Assessing for command hallucinations is important, especially given the client's recent aggressive behavior. Understanding the presence of such hallucinations can guide the treatment plan and safety measures.
E. Establish clear limits for expected behaviors: Setting clear expectations for behavior helps the client understand acceptable conduct and promotes a safer environment. This can be particularly important for clients with paranoid personality disorder who may struggle with interpersonal relationships.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "You should follow up with your regular doctor in the next few months so they can manage your new diagnosis.": While it's important for the client to maintain their relationship with their regular doctor, this response does not emphasize the specific need for mental health follow-up, which is crucial for managing borderline personality disorder.
B. "It is recommended that you receive follow-up care from a mental health provider after you are discharged.": This response appropriately emphasizes the importance of ongoing care from a mental health provider. Clients with borderline personality disorder often benefit from specialized therapy and support to manage symptoms and improve coping strategies.
C. "Since you have such a good relationship with your family practice provider, you do not need to see a mental health provider.": This response minimizes the importance of specialized mental health care for managing borderline personality disorder. Even if the client has a good relationship with their family practice provider, ongoing mental health support is essential.
D. "You have made such great progress here. I can see why you feel so well.": This response is not appropriate as it may invalidate the client's concerns and oversimplify their progress. It does not address the need for continued mental health support, which is vital for the client's ongoing care.
Correct Answer is C
Explanation
A. Opiate withdrawal: The Abnormal Involuntary Movement Scale (AIMS) test is not used to assess opiate withdrawal. Opiate withdrawal symptoms typically involve physical and psychological effects, such as anxiety, muscle aches, and gastrointestinal distress, which are evaluated using different assessment tools.
B. Lithium toxicity: The AIMS test is not applicable for assessing lithium toxicity. Symptoms of lithium toxicity can include tremors, confusion, and gastrointestinal issues, but these require different assessment methods rather than the AIMS scale.
C. Tardive dyskinesia: The AIMS test is specifically designed to evaluate and monitor involuntary movements associated with tardive dyskinesia, a potential side effect of long-term use of antipsychotic medications. This scale helps identify abnormal movements in clients and aids in managing their treatment effectively.
D. Alcohol withdrawal: The AIMS test is not intended for assessing alcohol withdrawal. Alcohol withdrawal is typically evaluated using clinical scales that focus on symptoms such as tremors, sweating, agitation, and hallucinations, rather than the involuntary movements assessed by the AIMS test.
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