The nurse is caring for a client with schizoaffective disorder and type 2 diabetes mellitus who receives a prescription for a second generation antipsychotic. The client expresses concern to the nurse about the effect of this antipsychotic on blood glucose levels. Which response should the nurse make?
"This medication may cause watery eyes and diarrhea. These will go away within 2 weeks."
"Side effects are not likely with this type of medication. There should be no need to worry."
"I can provide an education sheet with your discharge papers. What is your primary language?"
"This type of medication is generally well tolerated. Tell me more about your concerns."
The Correct Answer is D
Choice A rationale: The nurse's response regarding watery eyes and diarrhea is not directly related to the client's concern about the medication's effect on blood glucose levels.
Choice B rationale: This response minimizes the potential side effects, which is not accurate. Second-generation antipsychotics are associated with metabolic side effects, including changes in blood glucose levels.
Choice C rationale: Offering an education sheet is helpful but does not directly address the client's specific concerns about the medication's impact on blood glucose levels.
Choice D rationale: This response acknowledges the client's concern, provides information about the general tolerability of the medication, and invites the client to share more about their specific worries. It encourages open communication and allows the nurse to address the client's concerns more effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Asking the client about recent substance use is essential in assessing potential intoxication or withdrawal, which could contribute to the client's confused state. However, performing a mental status exam is the most important action to take.
Choice B rationale: The most important action for the nurse to take is to perform a mental status exam. This will help the nurse to assess the client's level of consciousness, orientation, memory, attention, mood, affect, thought process, and judgment. The mental status exam will also help the nurse to identify any signs of psychosis, delirium, dementia, or other mental disorders that may explain the client's behavior. Choice C rationale: Assessing the client from head-to-toe is a general nursing action but does not address the immediate need related to potential substance use. Choice D rationale: Determining the number of previous hospitalizations is relevant but does not address the current concern of substance use contributing to confusion.
Correct Answer is D
Explanation
Choice A rationale: "I know that bathing helps prevent infectious diseases" is a factual statement but may not necessarily reflect progress in the client's overall functioning and engagement in self-care. It focuses on the practical aspect of bathing rather than the client's motivation and insight.
Choice B rationale: "Others say I am dirty and smell badly, so I will bathe" suggests an external motivation rather than intrinsic motivation. Progress is better indicated when the client expresses a personal desire to engage in self-care activities.
Choice C rationale: "I will take a bath today as requested" indicates compliance with external requests rather than an internal desire to care for oneself. It is essential to foster the client's intrinsic motivation for self-care.
Choice D rationale: "I feel good when I take care of myself" reflects an internal motivation and positive reinforcement associated with self-care. This statementsuggests progress in the client's willingness to engage in personal hygiene activities.
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