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Wearing sunscreen when going outside to prevent effects of sun sensitivity is important for clients taking certain antipsychotic medications, but it is not the most critical instruction. While fluphenazine can cause photosensitivity, the risk of developing involuntary movements (extrapyramidal symptoms) is a more immediate concern that could significantly affect the client’s quality of life.

Drinking water frequently throughout the day is generally good advice for overall hydration, but fluphenazine does not significantly increase thirst. While maintaining hydration is important, the focus should be on the potential for serious side effects like involuntary movements, making this instruction secondary in priority.

Checking blood pressure daily and notifying the healthcare provider if it increases is relevant for some medications, particularly antihypertensives or those that can cause orthostatic hypotension. However, with fluphenazine, the more critical instruction revolves around recognizing and responding to neurological side effects rather than routine blood pressure monitoring, making this less of a priority.

Explain that these beliefs are related to her illness: While it is important to educate the client about their illness, directly challenging their delusions may increase distrust and anxiety. This approach might make the client feel misunderstood and less likely to trust the nurse.
 

Explain that distrust is related to feeling anxious: This explanation might not be well-received by the client and could be perceived as dismissive of their concerns. It may not effectively address the client’s immediate need for trust and reassurance.
 

Offer to keep the belongings at the nurse’s desk: This action might be perceived as an attempt to take control of the client’s belongings, which could reinforce their delusions and decrease trust. It is important to respect the client’s need to keep their belongings close to them.

Providing education on methods to enhance sleep may be helpful, especially since hypersomnia is a symptom. However, simply focusing on sleep does not address the broader functional impairments that the client is experiencing. While improving sleep hygiene can contribute to overall well-being, it is not the most comprehensive approach for facilitating a return to normal functioning.

Encouraging the client to exercise can be beneficial, as physical activity is known to have positive effects on mood and energy levels. However, for someone experiencing significant psychomotor retardation and amotivation, initiating an exercise routine can be daunting and may not be the most immediate or effective intervention. A structured approach is often more helpful in these cases.

Suggesting that the client develop a list of pleasurable activities could provide some motivation, but it may not be sufficient on its own, especially given the client's current level of amotivation. While identifying pleasurable activities is valuable, it is essential to pair this with a structured plan that encourages active participation and accountability, making the structured activities approach more effective in this context.

Sitting within two feet of the client may enhance feelings of safety and security for some individuals, but for others, it could feel intrusive or overwhelming. Establishing an appropriate personal distance is essential, and too close of a proximity might create discomfort, especially in a mental health setting where clients may already feel vulnerable.

Dimming the lights in the room can create a calming atmosphere; however, excessive dimness might hinder visibility and affect communication. While lighting can influence mood, it’s crucial to strike a balance that allows the client to feel comfortable without compromising the ability to engage effectively during the interview.

Positioning a table between the client and the nurse may provide a sense of personal space, but it can also create a physical barrier that may hinder open communication and rapport-building. Establishing a connection is important in mental health interviews, and a table might inadvertently foster feelings of separation or defensiveness.

While blood glucose levels can be relevant in the context of overall health and any potential metabolic syndrome concerns, they are not as directly related to lithium therapy as renal function. Blood glucose levels do not significantly impact the safety or effectiveness of lithium.

A white blood count (WBC) can be important in assessing for potential infections or hematological disorders, but it is not the primary focus when starting lithium. Lithium does not typically have a direct effect on white blood cell levels, making this finding less critical compared to renal function.

Alkaline phosphatase levels are primarily related to liver function and bone health. While monitoring liver function is important in general, it is not as directly pertinent to the initiation of lithium therapy as assessing renal function through serum creatinine levels. Therefore, this laboratory finding is less of a priority in this context.

Praising the client for her new behavior can be encouraging and may boost her self-esteem. However, it’s essential to approach this cautiously, as excessive praise might overwhelm her or be perceived as insincere. While positive reinforcement is valuable, it should not be the sole focus of the intervention.

Offering her a choice of activities can promote autonomy and encourage engagement, but given her recent shift from despondency to exhibiting energy, it’s crucial to assess her mood and mental state carefully first. Providing choices may be helpful, but it should be accompanied by vigilant monitoring to ensure her safety.

Involving her in group therapy could facilitate social interaction and support, but it may not be appropriate immediately. After several days of nonverbal behavior, she may still be vulnerable. Group settings could be overwhelming, and her readiness to participate should be carefully evaluated.

Reviewing the healthcare provider's history and physical may provide some background on the client's overall health and medication history, but it won't specifically address the symptoms currently being observed. While this information is useful, it does not directly relate to the assessment of involuntary movements.

The baseline nursing admission assessment can offer insights into the client's initial condition and any prior neurological assessments. However, it may not contain the specific details necessary to evaluate the current symptoms of uncontrollable hand movements and tongue protrusion, which are indicative of potential tardive dyskinesia or other movement disorders.

Recent urine drug testing (UDT) results could help identify any illicit substance use or non-compliance with prescribed medications. However, UDT results would not provide a clear correlation to the motor symptoms observed. Understanding the client’s current medication compliance is important, but it is not as directly relevant as the assessment of involuntary movements.

While providing thorough explanations when cleansing the wound can be beneficial, excessive detail may overwhelm the client or create anxiety. It is important to communicate effectively, but the focus should be on providing care in a compassionate manner rather than on the specifics of the procedure, especially given the client’s emotional state.

Asking the client in a non-threatening manner why they cut their abdomen could be perceived as intrusive or confrontational, potentially leading to defensiveness or escalation of emotions. This approach may not be appropriate during a dressing change; instead, it may be more effective to address the reasons for self-harm in a separate therapeutic context when the client is more stable.

Requesting another staff member to assist with the dressing change might be necessary in certain situations, but it could also convey a sense of fear or discomfort regarding the client’s behavior. In this case, it is essential for the nurse to manage the situation confidently and compassionately, rather than distancing themselves from the client’s needs. Fostering a supportive environment is more important than involving additional staff at this moment.

Describing alternatives to becoming depressed over the student’s death is a positive step, as it shows the client is engaging in cognitive strategies to manage her emotions. However, while this indicates some progress, it is less impactful than taking active steps to address the issue, like becoming involved in advocacy or community efforts.

Confronting her parents about the hurt she felt as a child of alcoholic parents can be a significant therapeutic step, but it may not directly relate to her current coping with the loss of her student. While this confrontation may contribute to her overall healing, it does not necessarily indicate coping specifically related to the anxiety from the recent event.

Signing a safety contract with the nurse indicates that there may still be significant concerns regarding self-harm or emotional distress. While this is an important safety measure, it suggests that the client is not yet fully coping well with her anxiety, as it implies she is still in a vulnerable state rather than demonstrating effective coping mechanisms.

Allowing the client time alone to sort out feelings may seem supportive, but isolation can be detrimental, especially for someone who has recently attempted suicide. Social withdrawal can exacerbate feelings of despair and hopelessness. Instead, encouraging engagement with others and structured activities is often more beneficial.

Avoiding discussions about subjects that upset the client can lead to avoidance coping and prevent the client from processing important emotions. While it’s important to be sensitive to triggers, avoiding difficult topics may hinder therapeutic progress. Open dialogue is essential for healing and understanding.

Encouraging the client to interact with persons who are recovering from depression can provide valuable support and understanding; however, this may not be the most immediate intervention. The client may still be in a fragile state, and facilitating control through structured activities might be a more effective way to build confidence and a sense of community before introducing peer interactions.