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 B
Explanation
Choice A Rationale: While talking to a social worker could be beneficial, it may not address the client's immediate need for safety and comfort. Social work intervention is important, but the priority is to ensure the client feels secure in the current environment.
Choice B Rationale: Offering a safe place to relax is crucial as it addresses the client's immediate need for safety and security. Feeling safe can help reduce anxiety and allows the client to compose themselves before discussing their concerns in detail.
Choice C Rationale: Assuring an interview with the healthcare provider is important, but it does not prioritize the client's immediate emotional and psychological needs. The assurance of care is part of the overall treatment plan but is secondary to providing a safe environment.
Choice D Rationale: Asking the client to describe the stalker is part of the assessment process, but it is not the most important initial action. The client's immediate emotional state must be stabilized before any detailed information gathering can be effective.
Correct Answer is B
Explanation
Choice A rationale: Asking the client about recent substance use is essential in assessing potential intoxication or withdrawal, which could contribute to the client's confused state. However, performing a mental status exam is the most important action to take.
Choice B rationale: The most important action for the nurse to take is to perform a mental status exam. This will help the nurse to assess the client's level of consciousness, orientation, memory, attention, mood, affect, thought process, and judgment. The mental status exam will also help the nurse to identify any signs of psychosis, delirium, dementia, or other mental disorders that may explain the client's behavior. Choice C rationale: Assessing the client from head-to-toe is a general nursing action but does not address the immediate need related to potential substance use. Choice D rationale: Determining the number of previous hospitalizations is relevant but does not address the current concern of substance use contributing to confusion.
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