Medical History: Borderline personality disorder.

Alcohol use disorder.

History of suicidal ideation.

Medication Administration Record: Fluoxetine 20 mg PO daily.

Nurses' Notes: . 1500: Client admitted for evaluation and treatment following arrest for driving while under the influence of alcohol.

Client reports recent breakup of romantic relationship and subsequent job loss.

States, "I was too upset to go to work, and then they fired me. Like I needed that stress, too.”. 1700: Noted client has multiple cuts on arms and legs and there is a broken mirror with blood on it on the floor.

Client states, "I feel so alone.

There is no one that cares about me.”. For each potential nursing action, click to specify if the potential action is anticipated, nonessential, or contraindicated for the client.

Instruct the client to avoid foods with tyramine.

Apply wrist restraints.

Offer sympathy and attention to maladaptive behavior.

Encourage the client to talk about feelings prior to maladaptive behavior.

Maintain same staff members caring for the client.

Answer and Explanation

The Correct Answer is F

Choice A rationale:
Instructing the client to avoid foods with tyramine is not relevant in this case. Tyramine is associated with certain antidepressants known as MAOIs, but the client is taking Fluoxetine, which is an SSRI2.
Choice B rationale:
Applying wrist restraints might be necessary in extreme situations to ensure the client’s safety, but it should be a last resort and not the first response to self-harm.
Choice C rationale:
Offering sympathy and attention to maladaptive behavior could reinforce negative behaviors and is not recommended.
Choice D rationale:
Encouraging the client to talk about feelings prior to maladaptive behavior can be beneficial. It can help the client develop healthier coping mechanisms.
Choice E rationale:
Maintaining the same staff members caring for the client can provide consistency and stability, which can be beneficial for individuals with Borderline Personality Disorder.
Choice F rationale:
Initiating suicide precautions is crucial in this situation. The client has a history of suicidal ideation and is exhibiting self-harming behavior.
Choice G rationale:
Offering the client opportunities for physical exercise can be beneficial as it can help manage stress and improve mood.
Choice H rationale:
Exploring feelings of abandonment with the client can be beneficial. It can help the client process these feelings in a healthier way.

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Correct Answer is A

Explanation

Choice A rationale:

Twisting tongue movements are a common symptom of tardive dyskinesia (TD), a side effect of long-term use of antipsychotic medications like fluphenazine.

Choice B rationale:

Shuffling gait is more commonly associated with Parkinson’s disease and certain antipsychotic medications can cause Parkinson-like symptoms, but it is not a characteristic of TD2.

Choice C rationale:

Sudden onset of high fever is not associated with TD. It could be a sign of a serious condition like neuroleptic malignant syndrome, which requires immediate medical attention.

Choice D rationale:

Constant tapping of feet when sitting could be a sign of restlessness or akathisia, another potential side effect of antipsychotic medications, but it is not a specific sign of TD2.

A. Pseudoparkinsonism. B. Neuroleptic malignant syndrome. C. Acute dystonia. D. Tardive dyskinesia.

Correct Answer is B

Explanation

Choice A rationale:

Pseudoparkinsonism is a side effect of antipsychotic medications that mimics the symptoms of Parkinson’s disease, such as tremors and rigidity. It does not typically cause hyperpyrexia or diaphoresis.

Choice B rationale:

Neuroleptic malignant syndrome is a rare but serious side effect of antipsychotic medications. It can cause severe fever (hyperpyrexia), unstable blood pressure, and heavy sweating (diaphoresis)4.

Choice C rationale:

Acute dystonia is a condition of sudden, involuntary muscle contractions. It does not typically cause hyperpyrexia or diaphoresis.

Choice D rationale:

Tardive dyskinesia is a side effect of long-term use of antipsychotic medications, causing involuntary movements, especially around the mouth. It does not typically cause hyperpyrexia or diaphoresis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has schizophrenia which has been treated with fluphenazine for several years. Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?.

Correct Answer is A

Explanation

A nurse is assessing a client who is receiving treatment with multiple antipsychotic medications and who suddenly became ill. Findings include blood pressure changes, hyperpyrexia, and diaphoresis. The nurse should recognize that which of the following adverse effects may be occurring?

Correct Answer is B

Explanation

A nurse is teaching a client who has bipolar disorder and a prescription for lithium to recognize the manifestations of toxicity. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is preparing to teach a client about his prescription of lithium for the treatment of bipolar disorder. Which of the following statements should the nurse include in the teaching?

A nurse is caring for a client who has bipolar disorder and is taking lithium. The client reports blurred vision and ataxia. Which of the following actions should the nurse take?

A nurse is caring for a client who is experiencing suicidal thoughts. Which of the following actions should the nurse take?.

A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is bored. Which of the following activities is appropriate for the nurse to suggest to this client?

A nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following responses should the nurse make first?

A nurse is reviewing laboratory results for a client and notes a serum lithium level of 1.6 mEq/L. Which of the following manifestations should the nurse expect the client to report?.