Question

A client with schizophrenia receives a prescription for fluphenazine. Which instruction is most important for the nurse to include when teaching the client about this drug?

Answer 1

Correct Answers:

Notify your healthcare provider immediately if involuntary movements develop.

Rationale :

🔷 Fluphenazine is a typical antipsychotic that may cause extrapyramidal symptoms (EPS) and tardive dyskinesia, including involuntary tongue and facial movements.

🔷 Early recognition and reporting of these symptoms are crucial to prevent permanent damage.

🔷 While sun sensitivity and hydration are also important, neurological side effects are potentially irreversible and take priority.

🔷 EPS and tardive dyskinesia can severely impact quality of life if not promptly managed.

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Answer 2

Correct Answers:

Initiate short, frequent contacts with the client.

Rationale :

🔷 Short, consistent interactions help build trust and therapeutic rapport with clients who are suspicious or paranoid.

🔷 These clients often interpret long or intense interactions as threatening or manipulative.

🔷 Avoid challenging delusions at this stage, as it can cause distress or increased resistance.

🔷 Predictable, brief visits foster a sense of security and comfort.

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Answer 3

Correct Answers:

Teach the client to develop a plan for daily structured activities.

Rationale :

🔷 Clients with major depressive disorder often experience amotivation and psychomotor slowing, requiring structured support.

🔷 A planned schedule promotes engagement, predictability, and purpose, which counteract symptoms.

🔷 Daily structure encourages behavioral activation and gradually rebuilds function and confidence.

🔷 This strategy aligns with CBT-based interventions for depression recovery.

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Answer 4

Correct Answers:

Reduce the noise level in the room by turning off the television and radio.

Rationale :

🔷 A quiet and distraction-free environment is essential to facilitate effective communication during a psychiatric interview.

🔷 Reducing environmental stimuli supports the client’s ability to focus and decreases anxiety.

🔷 Other options (like dim lighting or physical barriers) may increase discomfort or reduce safety.

🔷 Noise can exacerbate symptoms of anxiety, paranoia, or agitation.

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Answer 5

Correct Answers:

Serum creatinine.

Rationale :

🔷 Lithium is nephrotoxic and excreted through the kidneys, making it critical to assess renal function before and during therapy.

🔷 Elevated creatinine may indicate impaired clearance, increasing the risk of lithium toxicity.

🔷 Monitoring kidney function helps prevent long-term damage and supports safe dosing.

🔷 Blood glucose and liver enzymes are not as relevant to lithium’s pharmacokinetics.

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Answer 6

Correct Answers:

Observe her actions continuously.

Rationale :

🟢 A sudden improvement in mood and energy in a previously withdrawn and depressed client may indicate increased suicide risk due to regained motivation to act.

🟢 Continuous observation ensures immediate intervention if the client exhibits self-harming behaviors.

🟢 Praising or involving in group therapy is premature until safety is ensured.

🟢 Suicide prevention is the top priority in depressive disorders showing abrupt behavioral changes.

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Answer 7

Correct Answers:

Abnormal Involuntary Movement Scale (AIMS).

Rationale :

🟢 The AIMS tool is specifically used to assess extrapyramidal symptoms (EPS), especially tardive dyskinesia in clients taking antipsychotic medications.

🟢 Symptoms such as tongue protrusion and hand movements suggest the onset of this side effect.

🟢 Tracking AIMS scores over time helps evaluate progression or improvement with treatment adjustments.

🟢 This clinical tool supports early intervention and medication safety.

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Answer 8

Correct Answers:

Perform the dressing change in a non-judgmental manner.

Rationale :

🟢 Borderline personality disorder clients need a consistent and non-judgmental approach to reduce shame and foster trust.

🟢 Judging or interrogating can reinforce maladaptive coping and worsen self-harm behavior.

🟢 The goal is to maintain therapeutic neutrality while providing necessary wound care.

🟢 Neutral care models effective emotional regulation and boundaries.

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Answer 9

Correct Answers:

Becomes the faculty sponsor for Students Against Drunk Driving (SADD).

Rationale :

🟢 Taking an active, prosocial role in advocacy (e.g., sponsoring SADD) reflects healthy coping and channeling grief into purposeful action.

🟢 This approach transforms emotional pain into constructive behavior and promotes resilience.

🟢 It demonstrates the ability to process trauma and reintegrate meaningfully into the community.

🟢 It reflects adaptive grieving and engagement.

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Answer 10

Correct Answers:

Encourage activities that allow the client to exert control over the client's environment.

Rationale :

🟢 After multiple recent losses, promoting a sense of control helps restore personal agency and combat helplessness.

🟢 This builds self-efficacy and reduces suicide risk by creating structure and purpose.

🟢 Avoiding topics or isolating the client can worsen withdrawal and depression.

🟢 Empowerment strategies are essential in suicide recovery plans.

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RN HESI Nurs2520 Psychiatric Exam II

No.

1 :
A client with schizophrenia receives a prescription for fluphenazine. Which instruction is most important for the nurse to include when teaching the client about this drug?

2 :
The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them.
Which nursing action will promote trust?

3 :
A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and amotivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?

4 :
The nurse is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview?

5 :
The healthcare provider prescribes lithium carbonate for a client diagnosed with bipolar, manic depression. It is most important for the nurse to review which laboratory finding prior to beginning the drug therapy?

6 :
After several days of being despondent and nonverbal, a female client with depression begins to talk and exhibit energy.
Which action should the nurse implement?

7 :
When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client's record should the nurse review?

8 :
The nurse is providing care for a client diagnosed with a borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the nurse use when changing this client's dressings?

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RN HESI Nurs2520 Psychiatric Exam II

No.

1 : A client with schizophrenia receives a prescription for fluphenazine. Which instruction is most important for the nurse to include when teaching the client about this drug?

2 : The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them.Which nursing action will promote trust?

3 : A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and amotivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?

4 : The nurse is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview?

5 : The healthcare provider prescribes lithium carbonate for a client diagnosed with bipolar, manic depression. It is most important for the nurse to review which laboratory finding prior to beginning the drug therapy?

6 : After several days of being despondent and nonverbal, a female client with depression begins to talk and exhibit energy.Which action should the nurse implement?

7 : When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client's record should the nurse review?

8 : The nurse is providing care for a client diagnosed with a borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the nurse use when changing this client's dressings?

1 :
A client with schizophrenia receives a prescription for fluphenazine. Which instruction is most important for the nurse to include when teaching the client about this drug?

2 :
The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them.
Which nursing action will promote trust?

3 :
A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and amotivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?

4 :
The nurse is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview?

5 :
The healthcare provider prescribes lithium carbonate for a client diagnosed with bipolar, manic depression. It is most important for the nurse to review which laboratory finding prior to beginning the drug therapy?

6 :
After several days of being despondent and nonverbal, a female client with depression begins to talk and exhibit energy.
Which action should the nurse implement?

7 :
When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client's record should the nurse review?

8 :
The nurse is providing care for a client diagnosed with a borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the nurse use when changing this client's dressings?