During admission to the psychiatric unit, a client is extremely anxious and reports being worried about the sun coming up the next day. Which intervention is most important for the nurse to implement during the admission process?

Remain calm and use a matter-of-fact approach.

B Assist the client in developing alternative coping skills.

Administer an as needed (PRN) sedative to help relieve anxiety.

Ask the client why she is so anxious.

Answer and Explanation

The Correct Answer is A

Choice A rationale: Remaining calm and using a matter-of-fact approach helps provide a sense of security and reduces anxiety in the client during admission.
Choice B rationale: Assisting the client in developing alternative coping skills is important but may not be the first action during the initial admission process.

Choice C rationale: Administering a sedative may be considered if the client's anxiety is severe, but understanding and addressing the underlying cause of anxiety is the priority.
Choice D rationale: Asking the client why she is anxious may be appropriate, but the initial focus is on providing a calming and supportive environment during admission.

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Correct Answer is C

Explanation

Choice A rationale: Individual addiction counseling may be beneficial for the client but does not address the immediate physiological issue of Wernicke encephalopathy. Thiamine replacement is the priority.

Choice B rationale: Initiating disulfiram teaching is not relevant to the management of Wernicke encephalopathy. Disulfiram is used for alcohol aversion therapy, not thiamine deficiency.

Choice C rationale: Thiamine administration is the most critical intervention for Wernicke encephalopathy caused by alcohol addiction. Thiamine deficiency is a key factor in the development of this condition.

Choice D rationale: Nutrition referral may be important for the client's overall well being, but it is not the priority when the client is experiencing Wernicke encephalopathy. Immediate thiamine replacement is essential.

A. Document the finding on the Abnormal Involuntary Movement Scale. B. Assist the client in recognizing her manifestations of anxiety. C. Prepare to initiate seizure precautions for the client's safety. D. Advise the client that she has developed tolerance to the medication

Correct Answer is A

Explanation

Choice A rationale: Documenting the finding on the Abnormal Involuntary Movement Scale (AIMS) is appropriate. The AIMS is a standardized tool used to assess and document abnormal movements associated with antipsychotic medications, such as tardive dyskinesia.

Choice B rationale: Assisting the client in recognizing her manifestations of anxiety is unrelated to the observed foot tapping and does not address the potential side effects of antipsychotic medication.

Choice C rationale: Preparing to initiate seizure precautions for the client's safety is not indicated based on the observed foot tapping. Seizure precautions are not typically associated with antipsychotic medication side effects.

Choice D rationale: Advising the client that she has developed tolerance to the medication is speculative and not supported by the information provided. The observed foot tapping may be indicative of extrapyramidal side effects rather than tolerance.

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During admission to the psychiatric unit, a client is extremely anxious and reports being worried about the sun coming up the next day. Which intervention is most important for the nurse to implement during the admission process?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who experiences memory loss is diagnosed with Wernicke encephalopathy caused by alcohol addiction. Which intervention is most important for the nurse to implement?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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