The nurse is caring for a client diagnosed with Severe Intellectual Disability. Which of the following characteristics should the nurse recognize to be associated with Severe Intellectual Disability?
Other than possible coordination problems, the client's psychomotor skills are not affected.
The client communicates wants and needs by "acting out behaviors.”
The client can perform some self-care activities independently.
The client has advanced speech development.
The Correct Answer is B
Choice A rationale:
Other than possible coordination problems, the client's psychomotor skills are not affected. Severe Intellectual Disability (ID) is characterized by significant limitations in intellectual functioning as well as adaptive behaviors. Coordination problems are not a primary characteristic of severe ID. The main focus is on cognitive and adaptive deficits.
Choice B rationale:
The client communicates wants and needs by "acting out behaviors." Severe ID can lead to challenges in effective communication. "Acting out behaviors" such as tantrums, aggression, or other disruptive actions might be the client's way of expressing themselves when they are unable to communicate verbally or effectively due to their cognitive limitations.
Choice C rationale:
The client can perform some self-care activities independently. Severe ID typically involves significant impairments in adaptive functioning, which includes self-care activities. The ability to perform some self-care activities independently is not consistent with the characteristics of severe ID.
Choice D rationale:
The client has advanced speech development. Severe ID is associated with delayed or impaired speech and language development. Advanced speech development would be contradictory to the diagnosis of severe ID, as this condition is characterized by substantial limitations in communication skills.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nurse should prioritize the safety and well-being of both clients involved. Assisting the client with late-stage Alzheimer's disease to the correct room is important to prevent any further confusion or distress. Alzheimer's disease often causes cognitive impairment, memory loss, and disorientation, which can lead to situations where the individual may not recognize their surroundings or the people around them. Guiding the client back to their own room will help reduce confusion, agitation, and potential conflicts with other clients.
Choice B rationale:
Medicating the patient with antipsychotics is not the most appropriate initial action in this situation. Antipsychotic medications are often used to manage severe behavioral disturbances associated with conditions like schizophrenia or dementia, but their use should be carefully considered due to potential side effects. In this scenario, addressing the immediate situation and guiding the client back to their room is more appropriate than resorting to medication.
Choice C rationale:
Moving the client to a room at the end of the hall is not the best choice because it doesn't directly address the current situation. While changing the client's room might be considered in some cases to reduce agitation or wandering, it's not the immediate action needed when the client is found in another client's bed. Guiding the client to the correct room is the priority.
Choice D rationale:
Placing the client in restraints is not an appropriate choice in this situation. Restraints should only be used as a last resort for ensuring the safety of the client or others when less restrictive interventions have failed. Placing a client with Alzheimer's disease in restraints can be traumatic and lead to increased agitation and psychological distress.
Correct Answer is C
Explanation
The correct answer is choice C. Pseudoparkinsonism.
Choice A rationale:
Tardive dyskinesia is a long-term side effect of antipsychotic medications characterized by repetitive, involuntary movements, often around the mouth, such as lip-smacking, tongue protrusion, and chewing movements. It does not typically present with impaired gait and tremors.
Choice B rationale:
Acute dystonia involves sudden, severe muscle contractions, often affecting the neck, face, and back. Symptoms include twisting movements and abnormal postures, but it does not usually cause impaired gait and tremors.
Choice C rationale:
Pseudoparkinsonism is an adverse effect of antipsychotic medications that mimics the symptoms of Parkinson’s disease, including bradykinesia (slowness of movement), rigidity, tremors, and postural instability. The impaired gait and uncontrollable tremors observed by the nurse are characteristic signs of pseudoparkinsonism.
Choice D rationale:
Neuroleptic malignant syndrome is a rare but life-threatening reaction to antipsychotic medications. It presents with symptoms such as high fever, muscle rigidity, altered mental status, and autonomic dysfunction (e.g., unstable blood pressure, sweating). It does not typically present with impaired gait and tremors.
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