A psychiatric-mental health nurse is conducting an initial interview with a client admitted for hallucinations and abdominal pain. The client is focused on the pain and cannot concentrate on the assessment questions being asked. What is the initial desired outcome of the client?

client's anxiety level decreased

client's pain level decreased

assessment completed

client understood the importance of the assessment

Answer and Explanation

The Correct Answer is B

A. client's anxiety level decreased: While reducing anxiety is important, it is not the initial priority when a client is experiencing physical pain that is affecting their ability to engage in the assessment.

B. client's pain level decreased: The initial desired outcome is to address the client's immediate physical pain. Once the pain is managed, the client will likely be better able to participate in the assessment and respond to questions about their mental health.

C. assessment completed: Completing the assessment is important, but it should not be prioritized over managing the client's immediate physical pain, which is currently hindering their ability to participate.

D. client understood the importance of the assessment: The client’s understanding of the assessment’s importance is less critical than addressing their immediate physical discomfort, which is a more pressing concern in this scenario.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D"]

Explanation

A. Monitoring the client for neuroleptic malignant syndrome for up to 2 months after initiating the drug. Neuroleptic malignant syndrome (NMS) is a rare but serious adverse effect of antipsychotic medications. Monitoring for NMS, especially during the first few months of treatment, is crucial.

B. Encouraging the client to report signs of diabetes, such as increased thirst, hunger, and urination. Some antipsychotics, particularly second-generation antipsychotics, are associated with an increased risk of metabolic syndrome, including diabetes. Clients should be educated to report symptoms suggestive of hyperglycemia.

C. Advising the client to report weight gain and skin rashes to the health care provider immediately. Weight gain is a common side effect, particularly with second-generation antipsychotics. Skin rashes could indicate an allergic reaction, including serious conditions like Stevens-Johnson syndrome, requiring immediate medical attention.

D. Using the Abnormal Involuntary Movement Scale (AIMS) to assess for neurologic adverse effects. The AIMS scale is used to assess for tardive dyskinesia and other extrapyramidal symptoms, which are potential adverse effects of antipsychotic medications.

E. Administering the medication subcutaneously when the client is unable to swallow effectively. Antipsychotic medications are generally not administered subcutaneously. If a client cannot swallow, an alternative route such as intramuscular injection or an orally disintegrating tablet might be used.

A. hypokalemia or hyponatremia. B. acute gastrointestinal bleed. C. increased intracranial pressure. D. respiratory depression.

Correct Answer is D

Explanation

A. Hypokalemia or hyponatremia: While electrolyte imbalances are important, they are not the most immediate threat in the context of a heroin overdose.

B. Acute gastrointestinal bleed: An acute gastrointestinal bleed is not a primary concern with heroin overdose. It is not the most acute threat in this scenario.

C. Increased intracranial pressure: Increased intracranial pressure is not directly related to heroin overdose. The most pressing issue is related to the effects of the overdose.

D. Respiratory depression: Heroin overdose commonly leads to respiratory depression, which is the most immediate and life-threatening condition. Addressing respiratory depression is crucial for patient survival.

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A psychiatric-mental health nurse is conducting an initial interview with a client admitted for hallucinations and abdominal pain. The client is focused on the pain and cannot concentrate on the assessment questions being asked. What is the initial desired outcome of the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When administering an antipsychotic medication to a client diagnosed with schizophrenia, which action would be most appropriate for the nurse to include in the client's plan of care? Select all that apply.

Correct Answer is ["A","B","C","D"]

Explanation

Paramedics have brought a patient to the emergency department with a suspected heroin overdose. The nurse should recognize that the patient's most acute threat to health at this time is:

Correct Answer is D

Explanation

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