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 C

Explanation

A. While obtaining the client's history is important, ensuring privacy is a priority to maintain confidentiality and facilitate open communication.
B. Inviting a colleague to document is not the immediate priority; privacy is crucial in the initial stages of the interview.
C. Closing the examination room door for privacy is the most appropriate action to create a confidential and secure environment for the client to discuss their injuries and provide a history.
D. Requesting hospital security is not necessary at this point, as the spouse pacing outside does not necessarily indicate a security threat.

A. Avoid discussing subjects that upset the client B. Encourage activities that allow the client to exert control over his environment. C. Allow the client time alone to sort out his feelings. D. Encourage the client to interact with persons who are recovering from depression.

Correct Answer is B

Explanation

A. Avoiding discussing subjects that upset the client may hinder therapeutic communication and exploration of feelings, making it less effective for the client's recovery.
B. Encouraging activities that allow the client to exert control over his environment helps empower the client and regain a sense of agency, which is important for improving mental health.
C. Allowing the client time alone may be appropriate at times, but encouraging activities that promote control is a more proactive and empowering intervention.
D. Encouraging interaction with persons recovering from depression may be beneficial, but the client's need for control over his environment takes precedence in this scenario.

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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

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Correct Answer is C

Explanation

Correct Answer is B

Explanation

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