When assessing a female client who has been taking an antipsychotic medication for the past year, the nurse observes that the client demonstrates involuntary foot tapping while both feet are flat on the floor. The nurse plans to report the observation to the healthcare provider. Which additional action should the nurse take?
Document the finding on the Abnormal Involuntary Movement Scale.
Assist the client in recognizing her manifestations of anxiety.
Prepare to initiate seizure precautions for the client's safety.
Advise the client that she has developed tolerance to the medication
The Correct Answer is A
Choice A rationale: Documenting the finding on the Abnormal Involuntary Movement Scale (AIMS) is appropriate. The AIMS is a standardized tool used to assess and document abnormal movements associated with antipsychotic medications, such as tardive dyskinesia.
Choice B rationale: Assisting the client in recognizing her manifestations of anxiety is unrelated to the observed foot tapping and does not address the potential side effects of antipsychotic medication.
Choice C rationale: Preparing to initiate seizure precautions for the client's safety is not indicated based on the observed foot tapping. Seizure precautions are not typically associated with antipsychotic medication side effects.
Choice D rationale: Advising the client that she has developed tolerance to the medication is speculative and not supported by the information provided. The observed foot tapping may be indicative of extrapyramidal side effects rather than tolerance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. An overdose of cocaine can be lethal:
While this statement is accurate, it focuses on extreme outcomes rather than addressing the student's belief in their ability to control cocaine use. It may not encourage the student to reconsider their stance on trying the drug.
B. Addiction affects all aspects of one's life and one's family:
This response provides important information about the long-term consequences of addiction but does not directly counter the student's claim about their ability to control initial use. It may not be as impactful in the immediate context.
C. Denial of an addiction problem is often the first response to the behavior:
This response assumes the student is already using substances or experiencing addiction. It does not directly address the student's specific belief in their ability to control their actions after trying cocaine.
D. Mind-altering drugs take away one's ability to make good decisions:
This response is most appropriate because it directly challenges the student's confidence in their ability to control their behavior. It provides a logical explanation of why experimenting with cocaine is inherently risky, as it impairs judgment and decision-making, making it harder to "stop" as they claim
Correct Answer is B
Explanation
Choice A rationale: Encouraging an increase in oral fluids is a general intervention but may not address the specific concern related to a sore throat and elevated temperature.
Clozapine requires monitoring for potential agranulocytosis, and an infection should be ruled out with a complete blood count (CBC).
Choice B rationale: Obtaining a specimen for a complete blood count (CBC) is crucial to assess for clozapine-induced agranulocytosis, a potentially life-threatening side effect. A sore throat and fever are red flags for possible infection.
Choice C rationale: Completing an Abnormal Involuntary Movement Scale (AIMS) is not relevant to the current situation. A sore throat and fever require immediate attention to rule out infection.
Choice D rationale: Administering a PRN dose of acetaminophen may help reduce fever, but the priority is to investigate the potential cause of the symptoms. Obtaining a CBC is essential.
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