A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this clients safety?
Note escalating behaviors and intervene immediately
interpret attempts at communication
Assess for medication noncompliance
Assess triggers for bizarre, inappropriate behaviors
The Correct Answer is A
A. Note escalating behaviors and intervene immediately:
This option prioritizes the client's safety by addressing escalating behaviors promptly. Bizarre behaviors, neologisms, and thought insertion may indicate a severe episode of psychosis, and timely intervention is crucial to prevent harm to the client or others.
B. Interpret attempts at communication:
While understanding and interpreting communication are important, in a situation with escalating behaviors and potential safety concerns, immediate intervention takes precedence. Communication interpretation can follow once the safety of the client has been ensured.
C. Assess for medication noncompliance:
Medication noncompliance can contribute to exacerbation of symptoms, but in an acute situation where safety is a concern, addressing immediate behaviors takes precedence. Medication assessment can be done in the context of a more comprehensive assessment after the immediate safety concerns have been addressed.
D. Assess triggers for bizarre, inappropriate behaviors:
Identifying triggers is important for understanding the underlying causes of the behavior, but in the context of escalating behaviors and potential safety issues, immediate intervention to de-escalate the situation is the priority. Triggers can be explored once the immediate safety concerns are addressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incorrect. Falling asleep in the chair and refusing to eat lunch is not indicative of tardive dyskinesia (TD). TD is characterized by involuntary movements, not by changes in sleep patterns or appetite.
B. Correct. Grimacing and lip smacking are characteristic movements associated with tardive dyskinesia. TD is a side effect of long-term use of typical antipsychotic medications, and it involves involuntary, repetitive movements, often involving the face and mouth.
C. Incorrect. Excessive salivation and drooling are not specific to tardive dyskinesia. These symptoms may occur due to various reasons, and TD is primarily associated with abnormal, involuntary movements.
D. Incorrect. Experiencing muscle rigidity and tremors is more characteristic of other side effects or conditions, such as extrapyramidal symptoms, but it is not specific to tardive dyskinesia. TD typically involves repetitive, involuntary movements rather than tremors.
Correct Answer is C
Explanation
A. Dry mouth and urinary retention: These symptoms are not typically associated with the side effects of clozapine. Dry mouth is a common side effect of many antipsychotic medications, but urinary retention is not a typical side effect of clozapine.
B. Akinesia and insomnia: Akinesia (lack of movement) is not a common side effect of clozapine. Insomnia can occur with various antipsychotic medications but does not typically warrant immediate intervention unless severe or persistent.
C. Sore throat, fever, and malaise: These symptoms can indicate a potentially serious side effect known as agranulocytosis, which is a significant reduction in white blood cell count. Clozapine is associated with an increased risk of agranulocytosis. If a client experiences symptoms such as sore throat, fever, or malaise, it may indicate a severe drop in white blood cell count, and immediate medical attention is necessary.
D. Akathisia and hypersalivation: Akathisia (restlessness) is a known side effect of antipsychotic medications, but it is not typically associated with immediate severe medical risks. Hypersalivation is a common side effect but does not usually require immediate intervention unless severe.
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