Question

A nurse is caring for a client who has a serious mental illness and has developed tardive dyskinesia from anti-psychotic medication use. Which of the following adverse effects from anti-psychotic medication use would be expected for the client?

Answer 1

Correct Answers:

Uncontrolled movements around the mouth

Rationale :

🧠Tardive dyskinesia is a neurological disorder caused by long-term use of antipsychotic medications, especially typical ones.

💊It manifests as involuntary, repetitive movements such as lip-smacking, tongue protrusion, and grimacing.

⚠️These movements occur due to dopamine receptor hypersensitivity in the basal ganglia from prolonged dopamine blockade.

👩‍⚕️Early identification and medication adjustment are essential to prevent irreversible motor impairment.

📌Core Message

Tardive dyskinesia involves involuntary mouth and facial movements due to long-term antipsychotic use.

Answer 2

Correct Answers:

Somatic symptom disorder

Rationale :

🧩Somatic symptom disorder is characterized by chronic physical complaints with no identifiable medical cause.

🧠Clients experience excessive anxiety and preoccupation with symptoms, leading to frequent healthcare visits.

🗣️Unlike factitious disorder, symptoms are not intentionally produced or faked.

📅This condition often develops from psychological distress manifesting as physical symptoms.

📌Core Message

Somatic symptom disorder presents with physical complaints without medical cause driven by psychological distress.

Answer 3

Correct Answers:

assess level of consciousness

Rationale :

🧠After electroconvulsive therapy (ECT), the priority assessment is the client’s level of consciousness.

💉ECT induces a controlled seizure, and post-procedure confusion or drowsiness is common.

🩺Assessing consciousness ensures airway safety and early detection of postictal complications.

👩‍⚕️Only after stabilization should teaching or follow-up care be initiated.

📌Core Message

After ECT, the priority is to assess the client’s consciousness to ensure airway and neurological safety.

Answer 4

Correct Answers:

White blood cell count

Rationale :

🧫Clozapine can cause agranulocytosis, a dangerous drop in white blood cells.

🩸This puts clients at risk for severe infections, making regular WBC monitoring essential.

💊The medication is withheld if WBC levels fall below safe limits, and the provider must be notified.

⚕️Monitoring ensures early detection of this potentially life-threatening side effect.

📌Core Message

Clozapine requires close WBC monitoring due to the risk of agranulocytosis.

Answer 5

Correct Answers:

Individual cognitive behavioral therapy

Rationale :

🧠Conduct disorder involves repetitive, antisocial, and aggressive behaviors violating social norms.

💬Cognitive behavioral therapy (CBT) helps identify and modify maladaptive thoughts and impulsive behaviors.

👩‍⚕️It focuses on problem-solving, emotional regulation, and improving social skills.

🚫Isolation or punishment can worsen behavior, whereas structured therapy promotes long-term improvement.

📌Core Message

CBT is the most effective therapy for improving behavioral control in conduct disorder.

Answer 6

Correct Answers:

Justice

Rationale :

⚖️Justice is an ethical principle that emphasizes fairness and equality in providing care.

📜It requires nurses to distribute resources, care, and attention fairly among all patients.

💁‍♂️HIPAA is a legal standard, not an ethical principle, while bias and torts are ethical or legal issues, not principles.

👩‍⚕️Recognizing justice ensures that every patient receives equal and unbiased treatment.

📌Core Message

Justice is the ethical duty to provide fair and equal treatment to all clients.

Answer 7

Correct Answers:

establishing clear and consistent boundaries

Rationale :

🧠Clients with borderline personality disorder (BPD) often struggle with emotional instability and fear of abandonment.

🚧Establishing boundaries prevents manipulation and maintains a safe therapeutic relationship.

💬Consistent limits promote trust, structure, and predictability, which reduce impulsive behaviors.

👩‍⚕️Once boundaries are established, education and therapy can proceed effectively.

📌Core Message

The priority in caring for BPD clients is to maintain clear and consistent boundaries for safety and stability.

Answer 8

Correct Answers:

Her underlying biological vulnerability interacted with the recent stressors to trigger symptoms.

Rationale :

🧠The diathesis-stress model proposes that genetic predisposition interacts with environmental stressors to cause mental illness.

👩🏻‍🤝‍🧑🏿The student’s family history represents the biological vulnerability (diathesis).

📚Failing exams acted as a precipitating stressor, triggering panic symptoms.

⚕️Thus, neither factor alone is sufficient, but their interaction explains symptom onset.

📌Core Message

The diathesis-stress model explains illness as the interaction of biological vulnerability and environmental stress.

Answer 9

Correct Answers:

Discuss the timeline of the relationship.

Rationale :

🧩In the orientation phase of the nurse-client relationship, boundaries and expectations are established.

🗣️This includes discussing the purpose, timeline, and termination of the relationship.

👩‍⚕️Doing so builds trust and clarity, helping the client feel safe and understood.

📅Work on stressors or problems begins later during the working phase.

📌Core Message

During the orientation phase, the nurse should clarify the relationship timeline to build trust and structure.

Answer 10

Correct Answers:

Racing thoughts and decreased need for sleep
Poor judgment and attention-seeking behavior
Flight of ideas and pressured speech
Grandiose delusions and Inflated self-esteem

Rationale :

🔥Acute mania in bipolar I disorder presents with hyperactivity, elevated mood, and impulsive behaviors.

💭Clients experience racing thoughts, pressured speech, and flight of ideas, reflecting cognitive hyperactivity.

🩺Poor judgment and grandiose delusions lead to risky behaviors and impaired decision-making.

😴Decreased need for sleep without fatigue is a classic sign distinguishing mania from depression.

📌Core Message

Mania is marked by racing thoughts, poor judgment, inflated self-esteem, and decreased need for sleep.

Examplify NUR 144 Unit-2

No.

1 :
A nurse is caring for a client who has a serious mental illness and has developed tardive dyskinesia from anti-psychotic medication use. Which of the following adverse effects from anti-psychotic medication use would be expected for the client?

2 :
A 25-year-old client presents with chronic pain in multiple locations, excessive anxiety about symptoms, and frequent healthcare visits. Despite extensive testing, no medical cause is found. Which diagnosis best fits this presentation?

3 :
The nurse is caring for a client who is receiving electroconvulsive therapy (ECT). The client returns to the unit post procedure. Which priority nursing intervention should the nurse implement?

4 :
A client with schizophrenia is started on clozapine. Which of the following should the nurse monitor most closely during treatment?

5 :
A nurse is caring for a 12-year-old diagnosed with conduct disorder. Which intervention should be prioritized in the treatment plan?

6 :
The nurse preceptor is reviewing the concept of ethical principles with a newly licensed nurse. Which of the following would the nurse include as an ethical principle?

7 :
What is the nurse's priority when taking care of a client with borderline personality disorder?

9 :
A nurse is caring for a client who has post-traumatic stress disorder. Which of the following actions should the nurse plan to take during the orientation phase of the nurse-client relationship?

10 :
A client with bipolar I disorder is experiencing acute mania. Which of the following symptoms would the nurse most likely observe? Select all that apply.

Examplify NUR 144 Unit-2

No.

1 : A nurse is caring for a client who has a serious mental illness and has developed tardive dyskinesia from anti-psychotic medication use. Which of the following adverse effects from anti-psychotic medication use would be expected for the client?

2 : A 25-year-old client presents with chronic pain in multiple locations, excessive anxiety about symptoms, and frequent healthcare visits. Despite extensive testing, no medical cause is found. Which diagnosis best fits this presentation?

3 : The nurse is caring for a client who is receiving electroconvulsive therapy (ECT). The client returns to the unit post procedure. Which priority nursing intervention should the nurse implement?

4 : A client with schizophrenia is started on clozapine. Which of the following should the nurse monitor most closely during treatment?

5 : A nurse is caring for a 12-year-old diagnosed with conduct disorder. Which intervention should be prioritized in the treatment plan?

6 : The nurse preceptor is reviewing the concept of ethical principles with a newly licensed nurse. Which of the following would the nurse include as an ethical principle?

7 : What is the nurse's priority when taking care of a client with borderline personality disorder?

9 : A nurse is caring for a client who has post-traumatic stress disorder. Which of the following actions should the nurse plan to take during the orientation phase of the nurse-client relationship?

10 : A client with bipolar I disorder is experiencing acute mania. Which of the following symptoms would the nurse most likely observe? Select all that apply.

1 :
A nurse is caring for a client who has a serious mental illness and has developed tardive dyskinesia from anti-psychotic medication use. Which of the following adverse effects from anti-psychotic medication use would be expected for the client?

2 :
A 25-year-old client presents with chronic pain in multiple locations, excessive anxiety about symptoms, and frequent healthcare visits. Despite extensive testing, no medical cause is found. Which diagnosis best fits this presentation?

3 :
The nurse is caring for a client who is receiving electroconvulsive therapy (ECT). The client returns to the unit post procedure. Which priority nursing intervention should the nurse implement?

4 :
A client with schizophrenia is started on clozapine. Which of the following should the nurse monitor most closely during treatment?

5 :
A nurse is caring for a 12-year-old diagnosed with conduct disorder. Which intervention should be prioritized in the treatment plan?

6 :
The nurse preceptor is reviewing the concept of ethical principles with a newly licensed nurse. Which of the following would the nurse include as an ethical principle?

7 :
What is the nurse's priority when taking care of a client with borderline personality disorder?

9 :
A nurse is caring for a client who has post-traumatic stress disorder. Which of the following actions should the nurse plan to take during the orientation phase of the nurse-client relationship?

10 :
A client with bipolar I disorder is experiencing acute mania. Which of the following symptoms would the nurse most likely observe? Select all that apply.