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:

Seizures and tremors

Rationale :

💫 Tardive dyskinesia hallmark: Involuntary, repetitive movements, often involving the face, lips, and tongue.

💫 Cause: Long-term use of antipsychotic medications, especially first-generation (typical) antipsychotics.

💫 Impact: Can affect eating, speaking, and social interaction; often irreversible.

💫 Nursing consideration: Monitor using tools like the Abnormal Involuntary Movement Scale (AIMS) and report promptly.

❌ Incorrect Answers:

Seizures and tremors

❌ While some antipsychotics can lower seizure threshold or cause tremors (extrapyramidal symptoms), these are not the hallmark of tardive dyskinesia.

Hallucinations and delusions

❌ These are symptoms of the mental illness itself, not an adverse effect of antipsychotic medications.

Muscle stiffness and tenderness

❌ This describes extrapyramidal side effects like dystonia or parkinsonism, not tardive dyskinesia, which is specifically uncontrolled involuntary movements.

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Answer 2

Correct Answers:

Somatic symptom disorder

Rationale :

🌟Somatic symptom disorder involves persistent physical symptoms that cause distress or significant disruption in daily life.

🌟 Multiple, chronic complaints (e.g., pain in various areas), excessive anxiety about symptoms, and repeated medical consultations despite negative test results.

🌟 Nursing focus: Provide consistent, supportive care, validate the patient’s experience, avoid unnecessary tests, and teach coping strategies for managing symptoms.

🌟 Differentiation: Unlike illness anxiety disorder, the emphasis is on actual physical symptoms, not just fear of illness.

❌ Incorrect:

Illness anxiety disorder – Focuses on fear of having a serious illness, rather than chronic physical symptoms.

Factitious disorder – Symptoms are intentionally fabricated for attention or secondary gain.

Conversion disorder – Symptoms are neurological (e.g., paralysis, blindness), not multiple widespread pain complaints.

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Answer 3

Correct Answers:

assess level of consciousness

Rationale :

🌟 After electroconvulsive therapy, the priority is to assess the client’s level of consciousness, as post-ECT confusion, disorientation, and short-term memory impairment are common.

🌟 Monitoring responsiveness ensures early detection of complications such as prolonged unconsciousness, hypoxia, or aspiration risk.

🌟 Assessment of airway protection and respiratory status depends on determining whether the client is awake, following commands, and oriented.

🌟 Establishing neurologic stability guides all other post-procedure care and determines when further interventions can safely occur.

❌ Initiate teaching — Teaching is ineffective immediately post-ECT due to memory impairment.

❌EEG — Not required post-procedure; monitoring is done by the ECT team.

❌ Monitor for seizure activity — The seizure occurs during ECT, not after return to the unit.

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Answer 4

Correct Answers:

White blood cell count

Rationale :

💠 Clozapine carries a high risk of agranulocytosis, a severe and potentially fatal drop in white blood cell (WBC) count, making hematologic monitoring the top priority.

💠 The nurse must ensure regular WBC and ANC (absolute neutrophil count) testing to detect early bone-marrow suppression.

💠 Loss of neutrophils significantly increases the risk of life-threatening infections, so early detection allows for immediate discontinuation of the drug and rapid intervention.

💠 This monitoring requirement is so critical that clozapine can only be dispensed through a specialized REMS (Risk Evaluation and Mitigation Strategy) program.

❌ Blood pressure — Important for many antipsychotics, but not the highest risk with clozapine.

❌ Electrolytes — Not typically affected by clozapine.

❌Liver function tests — Mild effects possible, but not the primary concern.

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Answer 5

Correct Answers:

Individual cognitive behavioral therapy

Rationale :

🔷 For conduct disorder, Cognitive Behavioral Therapy (CBT) is the most effective and prioritized intervention because it helps the child develop problem-solving skills, anger management strategies, and improved impulse control.

🔷 CBT addresses distorted thinking patterns that contribute to aggression, rule violation, and oppositional behaviors.

🔷 Early therapeutic intervention is essential to prevent the progression of conduct disorder into more severe antisocial behaviors in adolescence and adulthood.

🔷 CBT also provides structured behavioral modification and supports the development of pro-social behaviors, making it the foundation of treatment.

❌ Isolation from peers — Can worsen social dysfunction and aggression.

❌ Punishment — Ineffective and often reinforces negative behaviors.

❌ Immediate medication management — Medications are not first-line unless comorbid ADHD or mood disorders exist.

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Answer 6

Correct Answers:

Justice

Rationale :

🟢 Justice is a core ethical principle in nursing that refers to providing fair, equitable, and unbiased treatment to all clients.

🟢 It involves distributing resources and care based on need, ensuring that all clients receive appropriate and nondiscriminatory healthcare.

🟢 Justice guides nurses to uphold ethical decision-making, especially when prioritizing care or managing competing needs.

🟢 This principle is foundational in professional practice and is consistently reinforced in both ethics education and nursing codes of conduct.

❌Bias — Not an ethical principle; bias actually violates ethical practice.

❌HIPAA — A legal act focused on privacy, not an ethical principle.

❌Torts — A category of civil law violations, not an ethical principle.

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Answer 7

Correct Answers:

establishing clear and consistent boundaries

Rationale :

🔶 Clients with borderline personality disorder (BPD) commonly struggle with emotional instability, fear of abandonment, and shifting interpersonal patterns, making boundaries the priority intervention.

🔶 Establishing clear and consistent limits helps reduce impulsive behaviors, staff splitting, and emotional volatility, which are hallmark features of BPD.

🔶 Boundaries provide a predictable framework that decreases anxiety and helps the client build healthier relational patterns.

🔶 Once stability and safety are established through boundaries, other interventions such as therapy and coping-skill development can be introduced more effectively.

❌ Coping skills education — Important but not the first priority before boundaries are set.

❌ Group therapy — Beneficial later, but boundary-setting must occur first to maintain safety.

❌Medications — Can help, but medications do not address core interpersonal instability.

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Answer 8

Correct Answers:

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

Rationale :

💫 The diathesis–stress model explains that mental health symptoms emerge when a biological or genetic vulnerability (diathesis) interacts with environmental stressors, leading to symptom onset.

💫 In this case, the student’s family history of generalized anxiety disorder represents a biological predisposition that increases her sensitivity to stress.

💫 The recent exam failures acted as acute stressors, overwhelming her coping capacity and triggering panic symptoms.

💫 This interaction between vulnerability and stress is the central feature of the model and best accounts for why symptoms developed at this specific time.

❌ Stress alone caused the attacks — The model requires both vulnerability and stress, not stress alone.

❌ Family history alone is responsible — Vulnerability is important, but symptoms often remain latent without stressors.

❌ Childhood sensitivity = personality disorder — Not accurate; this does not indicate inevitability or a personality disorder.

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Answer 9

Correct Answers:

Discuss the timeline of the relationship.

Rationale :

🌼 During the orientation phase of the nurse-client relationship, the nurse establishes the purpose, roles, and expected duration of interactions, which helps build trust and safety for clients with post-traumatic stress disorder (PTSD).

🌼 Clients with PTSD often experience hypervigilance and fear of the unknown, making clear structure essential for reducing anxiety.

🌼 Discussing the timeline and expectations provides predictability, which helps the client feel safe enough to participate in therapeutic work later.

🌼 This phase focuses on forming the relationship, not on teaching or problem-solving, which occurs in later phases.

❌ Education — Teaching occurs in the working phase, not orientation.

❌Self-reflection — This is done before interacting with the client, not during orientation.

❌ Working on problem areas — This happens in the working phase, not the first phase.

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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 :

🟣 Racing thoughts and decreased need for sleep:

🟣 Clients in acute mania commonly exhibit rapid thought patterns, extreme energy, and a markedly reduced need for sleep without feeling tired.

🟣 These symptoms reflect an overstimulated central nervous system and heightened psychomotor activity.

🟣 The inability to rest increases risk for exhaustion and safety issues, requiring close monitoring.

🟣— Poor judgment and attention-seeking behavior:

🟣 Acute mania impairs judgment, leading to reckless spending, risky sexual behavior, and impulsivity.

🟣 Clients may also show attention-seeking behaviors, such as loud or inappropriate interactions, due to heightened energy and unstable mood.

🟣 These behaviors increase the risk of interpersonal conflict and harm.

🟣— Flight of ideas and pressured speech:

🟣 Flight of ideas describes rapidly shifting thoughts, often loosely connected, making communication difficult.

🟣 Pressured speech is fast, loud, and difficult to interrupt, a classic manifestation of manic acceleration.

🟣 These symptoms indicate significant cognitive and emotional dysregulation.

🟣 — Grandiose delusions and inflated self-esteem:

🟣 Clients in acute mania often exhibit grandiosity, such as believing they have special powers, wealth, or abilities.

🟣 This inflated self-esteem can escalate risk-taking behaviors and reduce cooperation with treatment.

🟣 Grandiose delusions reflect impaired reality testing, a hallmark of severe manic episodes.

❌ Incorrect Options:

❌ Social withdrawal — Seen in depression, not mania.

❌ Depressed mood — Opposite of manic elevation.

❌ Excessive sleeping — Mania is characterized by reduced sleep, not hypersomnia.

❌ Hopelessness — Typical of major depressive episodes, not acute mania.

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QLexNursing

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.

QLexNursing

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.