When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client’s record should the nurse review?

The healthcare provider’s history and physical.

Recent urine drug testing (UDT) results

Baseline nursing admission assessment

Abnormal Involuntary Movement Scale (AIMS)

Answer and Explanation

The Correct Answer is D

A.   The healthcare provider's history and physical may provide information about the client's overall health but may not specifically address the observed symptoms.
B.   Recent urine drug testing (UDT) results may reveal drug use but may not be directly related to the observed involuntary movements.
C. The baseline nursing admission assessment may provide general information but may not specifically address medication side effects.
D.   The Abnormal Involuntary Movement Scale (AIMS) is specifically designed to assess and document involuntary movements associated with psychotropic medications, making it the most relevant assessment tool in this situation.

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Correct Answer is D

Explanation

A. Telling the client that the voices they are hearing are not real may invalidate their experience and could increase their distress or resistance to the nurse's intervention.
B. While discussing strategies for the next occurrence might be helpful, it does not address the immediate situation or acknowledge the client's current experience.
C. Asking the client to focus on something else may be perceived as dismissive and may not effectively engage them in conversation or provide support.
D. Acknowledging that the client appears to be speaking with someone validates their experience without confirming the reality of the voices. This comment encourages the client to express themselves and provides an opening for further communication, allowing the nurse to assess the situation more effectively.

A. Marijuana is a highly addictive substance. B. Altering one’s ability to think clearly places self and others at risk. C. Healthcare providers sometimes prescribe marijuana to control nausea. D. Drug use has moral implications that should be discussed with parents.

Correct Answer is B

Explanation

A. While marijuana may not be considered highly addictive compared to some substances, the response should address the potential risks and consequences of marijuana use rather than focusing solely on addiction.
B. This response highlights the immediate concern of altering one's ability to think clearly, emphasizing potential risks to both the individual and others.
C. Healthcare providers prescribing marijuana for specific medical purposes does not directly address the student's concern about recreational use.
D. Discussing moral implications may be a subjective approach and may not provide concrete information about the potential risks associated with marijuana use.

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When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client’s record should the nurse review?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes a client with a history of psychosis repeatedly looking to the side and mumbling responses to no one present in that direction. Which comment is best for the nurse to make?

Correct Answer is D

Explanation

During a high school substance abuse class, a student tells the group, “I know that marijuana is not addicting, so why shouldn’t I use it? Which response is best for the nurse to provide?

Correct Answer is B

Explanation

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