A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting, and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take?

Have a staff member escort the client to her room.

Allow the client to pace alone until physically tired.

Instruct the client to sit down and stop pacing.

Walk with the client at a gradually slower pace.

Answer and Explanation

The Correct Answer is D

A) Have a staff member escort the client to her room:

Having a staff member escort the client to her room might be perceived as restrictive and could potentially escalate the client's anxiety. It's important to give the client some autonomy and not force them into isolation.

B) Allow the client to pace alone until physically tired:

While allowing the client to pace alone might seem like a non-intrusive option, it lacks the therapeutic engagement that can help the client feel supported and understood. It's important for the nurse to actively engage with the client to establish a therapeutic relationship.

C) Instruct the client to sit down and stop pacing:

Instructing the client to stop pacing could potentially increase their agitation and anxiety. Forcing the client to sit down against their wishes might lead to resistance and hinder the development of trust between the nurse and the client.

D) Walk with the client at a gradually slower pace:

This is the correct answer. Walking with the client at a gradually slower pace is a therapeutic approach that allows the nurse to build rapport, provide support, and help the client regulate their emotions. It respects the client's need for movement while also addressing their emotional state.

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Correct Answer is D

Explanation

A. “Taking the medication on an empty stomach will decrease your stomach upset."This is incorrect because taking chlorpromazine on an empty stomach can actually increase the risk of gastrointestinal irritation and upset. It’s generally recommended to take medications that can irritate the stomach lining with food or milk to help buffer the stomach.

B. “Lie down for 30 minutes after each dose to help prevent stomach upset.”This is not a recommended practice for preventing stomach upset. In fact, lying down immediately after taking medication can increase the risk of esophageal irritation and reflux, especially with certain medications.

C. “Talk to your provider about decreasing your dose of medication.”While discussing medication concerns with a healthcare provider is always a good idea, this response does not directly address the immediate issue of stomach upset. The provider might adjust the dose if necessary, but the primary recommendation for reducing stomach upset would be to take the medication with milk.

D. “Drink a glass of milk with each dose of your medication.”Drinking milk with chlorpromazine can help reduce stomach upset by buffering the stomach lining and reducing irritation. This is a common recommendation for medications that can cause gastrointestinal discomfort.

A. Brief Patient Health Questionnaire (Brief PHQ) B. Abnormal Involuntary Movements Scale (AIMS) C. Mental status examination (MSE) D. Scale for Assessment of Negative Symptoms (SANS)

Correct Answer is C

Explanation

A. Brief Patient Health Questionnaire (Brief PHQ):

The Brief PHQ is a screening tool used to assess symptoms of depression. While it may be relevant to assess mood and emotional well-being, it is not specific to evaluating cognitive functioning or cognitive disorders.

B. Abnormal Involuntary Movements Scale (AIMS):

The AIMS is used to assess involuntary movements, particularly in individuals taking antipsychotic medications. It is not directly related to assessing cognitive disorders.

C,. Mental status examination (MSE)

Explanation:

When admitting an older adult client with a suspected cognitive disorder, including a mental status examination (MSE) as part of the assessment is crucial. The MSE is a structured assessment of a client's current cognitive functioning, emotional state, and thought processes. It helps to evaluate memory, attention, language, perception, orientation, mood, and other cognitive and emotional domains.

D. Scale for Assessment of Negative Symptoms (SANS):

The SANS is used to assess negative symptoms in individuals with schizophrenia. It focuses on features such as affective blunting, alogia, anhedonia, and other negative symptoms. While it may provide important information about a client's mental state, it is not primarily used to assess cognitive disorders.

Assessing cognitive function is a key component when evaluating older adult clients for cognitive disorders such as dementia or other cognitive impairments. The MSE provides valuable information to guide diagnosis and treatment planning for these conditions.

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A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting, and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports an upset stomach after taking chlorpromazine. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is admitting an older adult client who has a suspected cognitive disorder. Which of the following inventories should be included as part of the admission assessment?

Correct Answer is C

Explanation

A nurse is observing & newly licensed nurse as she interacts with a client regarding his concerns about his relationship with his partner. Which of the following statements by the newly licensed nurse requires intervention by the nurse?

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