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.

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Assessing papillary reactions to light is important in a neurological assessment but is not the priority in this situation.

B. Measuring and recording abdominal girth is not relevant to the client's current symptoms.

C. Auscultating over the main stem bronchus is the priority action as the client's symptoms suggest potential airway compromise, possibly from inhalation injury or swelling. Early identification and management of airway issues are critical in burn patients.

D. Determining the time of last oral intake is part of a comprehensive assessment but is not the immediate priority when airway compromise is suspected.

A. Report findings to Adult Protective Services. B. Perform a thorough physical assessment. C. Confront the abuser about concerning actions. D. Develop a safety plan. E. Question the client in front of the suspected abuser. F. Take photographs to document the abuse or neglect. G. Throw away soiled clothing. H. Complete a comprehensive history.

Correct Answer is ["A","B","D","F","H"]

Explanation

A. Report findings to Adult Protective Services: Reporting to Adult Protective Services (APS) is essential when elder mistreatment is suspected. APS can investigate the situation further and take appropriate action to ensure the safety and well-being of the elder.

B. Perform a thorough physical assessment: Conducting a thorough physical assessment helps to identify any signs of abuse or neglect, such as pressure injuries, poor hygiene, or physical injuries. It provides necessary information to support the suspicion of mistreatment.

C. Confront the abuser about concerning actions: Confronting the abuser directly can be dangerous for the client and may interfere with the investigation. It is best to report concerns to appropriate authorities who can handle the situation professionally.

D. Develop a safety plan: Developing a safety plan is crucial to protect the client from immediate harm. This plan includes steps to ensure the client’s safety and well-being while further actions are being taken.

E. Question the client in front of the suspected abuser: Questioning the client in front of the suspected abuser could put the client at further risk of harm. It is important to ensure the client’s safety and privacy when gathering information.

F. Take photographs to document the abuse or neglect: Documenting findings through photographs can provide evidence of abuse or neglect, which is important for reporting and investigation purposes. This documentation should be done with caution and respect for privacy.

G. Throw away soiled clothing: Disposing of soiled clothing does not address the underlying issue of mistreatment and may destroy potential evidence. Soiled clothing should be documented and handled appropriately.

H. Complete a comprehensive history: Completing a comprehensive history helps to gather detailed information about the client’s living conditions, care needs, and any changes in their behavior or condition that might indicate mistreatment.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While the nurse is admitting a client with partial thickness burns to the upper extremities, chest, and abdomen, the client experiences difficulty swallowing. The client is drooling and anxious. Which intervention should the nurse implement first?

Correct Answer is C

Explanation

Patient Data Exhibits Which intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.

Correct Answer is ["A","B","D","F","H"]

Explanation

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? Select all that apply.

An older client with osteoarthritis reports increasing pain and stiffness in the right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of the symptoms?

A client tells the nurse about beginning an exercise program a month ago to lose weight and improve sleep. The client states, "It still takes at least two hours to fall asleep at night." Which action should the nurse implement?

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

The nurse is assessing a 3-month-old client who had a pyloromyotomy yesterday. This child should be medicated for pain based on which finding(s)? Select all that apply.

A client with generalized anxiety disorder does not want to communicate with friends, smokes 2 to 3 packages of cigarettes a day, and describes difficulty concentrating at work. Which coping strategy should the nurse include in the plan of care?