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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Telling the client they are out of control may escalate the situation and provoke further aggression. It is not a therapeutic or de-escalation technique.
Choice B rationale: Staying quietly with the client is a calm and non-confrontational approach. It allows the client to express emotions while conveying a supportive presence.
Choice C rationale: Distracting the client by offering finger foods may not be appropriate during a shouting episode, as it may be perceived as dismissive of the client's feelings or concerns.
Choice D rationale: Ignoring the client's acting-out behavior is not the best option. The nurse should acknowledge the client's emotions and provide support rather than ignoring the distress.
Correct Answer is D
Explanation
Choice A rationale: "I know that bathing helps prevent infectious diseases" is a factual statement but may not necessarily reflect progress in the client's overall functioning and engagement in self-care. It focuses on the practical aspect of bathing rather than the client's motivation and insight.
Choice B rationale: "Others say I am dirty and smell badly, so I will bathe" suggests an external motivation rather than intrinsic motivation. Progress is better indicated when the client expresses a personal desire to engage in self-care activities.
Choice C rationale: "I will take a bath today as requested" indicates compliance with external requests rather than an internal desire to care for oneself. It is essential to foster the client's intrinsic motivation for self-care.
Choice D rationale: "I feel good when I take care of myself" reflects an internal motivation and positive reinforcement associated with self-care. This statementsuggests progress in the client's willingness to engage in personal hygiene activities.
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