The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention?
Shuffling gait and stooped posture.
Rocks back and forth in the chair.
Muscle spasms of the back and neck.
Lip smacking and frequent eye blinking.
The Correct Answer is C
A. Shuffling gait and stooped posture are common side effects of antipsychotic medications and may require intervention but are not immediately dangerous.
B. Rocking back and forth in the chair can be a self-soothing behavior in individuals with schizophrenia and usually does not require immediate intervention.
C. Muscle spasms of the back and neck (dystonia) can be a sign of a serious side effect of antipsychotic medications known as extrapyramidal symptoms and require immediate intervention to prevent complications such as airway obstruction.
D. Lip smacking and frequent eye blinking can indicate tardive dyskinesia, a long-term side effect of antipsychotic medication, but it is not an immediate emergency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E"]
Explanation
A. Involve your mother in the decision-making process: Involving the client in decision-making can help maintain their sense of autonomy and dignity, and it can also alleviate some of the caregiver’s stress by sharing responsibilities and ensuring the client's preferences are considered.
B. Helping your mother should be easier than raising a child: Caregiving for an elderly parent can be just as challenging, if not more so, than raising a child. Comparing caregiving responsibilities to raising children may invalidate the caregiver’s feelings and experiences.
C. You made a promise to your mother that you need to keep: While promises can be important, emphasizing this can add additional pressure on the caregiver. Instead, focusing on practical support strategies and self-care might be more helpful.
D. Saying "no" to things involving the care of your mother is a selfish action: Caregivers need to set boundaries and prioritize their own well-being. Saying "no" when needed is essential to prevent burnout and maintain effective caregiving.
E. It is okay not to love or like your mother when you are caring for her: Acknowledging that it's normal to have complex emotions while caregiving can help the daughter understand that her feelings are valid and that seeking support or expressing her feelings is a healthy part of caregiving.
Correct Answer is D
Explanation
A. An older adult scheduled for foot amputation due to diabetes complications may have complex care needs requiring the expertise of an RN.
B. An adult with alcoholism, cirrhosis, and hepatic encephalopathy can present with unstable and complex health issues that require close monitoring by an RN.
C. An older client who is one day postoperative with a colostomy for colon cancer may require specialized care and education best provided by an RN.
D. An adult who is one day postoperative for a laparoscopic cholecystectomy is likely to have more predictable and routine care needs, making this client a suitable assignment for a PN under the supervision of an RN.
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