Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Which assessment tool is used to monitor clients for Tardive Dyskinesia?
A. AIMS Scale
The AIMS Scale refers to the Abnormal Involuntary Movement Scale and is used in the assessment of patients for the presence of involuntary movements across body regions. The score ranges from zero which denotes the absence of dyskinesia and four which stands for severe, maximal amplitude and persistence of the abnormal movements during the examination period. It is also used to monitor clients with tardive dyskinesia.
B. Hamilton Scale
the Hamilton scale is a multiple-item questionnaire used in the assessment of clients for depression and provides a guide for patient recovery evaluation.
C. Braden Scale
the Braden Scale is used in the assessment of clients for the risk of pressure ulcers.
D. Morse Scale
the Morse Scale is a Fall Risk Assessment tool used in assessing the probability of a client sustaining a fall.
This question is an excerpt from Nurse Dive's nursing test bank - ATI ns 130 Exam Psychosocial Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale: The AIMS Scale refers to the Abnormal Involuntary Movement Scale and is used in the assessment of patients for the presence of involuntary movements across body regions. The score ranges from zero which denotes the absence of dyskinesia and four which stands for severe, maximal amplitude and persistence of the abnormal movements during the examination period. It is also used to monitor clients with tardive dyskinesia.
Choice B rationale: the Hamilton scale is a multiple-item questionnaire used in the assessment of clients for depression and provides a guide for patient recovery evaluation.
Choice C rationale: the Braden Scale is used in the assessment of clients for the risk of pressure ulcers.
Choice D rationale: the Morse Scale is a Fall Risk Assessment tool used in assessing the probability of a client sustaining a fall.
Similar Questions
Haldol 2mg IM stat has been ordered for the agitated client. Haldol is available in 5mg/ml. How many mls will you administer?
Full Explanation
To answer the above question we will use the formula:
Dose (ml)= ordered dose (mg)/ Concentration (mg/ml)
= 2mg/5mg/ml
= 0.4 ml
While the nurse is talking with a female client, the client becomes silent for several seconds. Which is the nurse's best response?
A. To tell the client that help can be more effective if she shares her feelings
this may imply that the client is not cooperating and may make them feel guilty thus discouraging any further communication which may be useful in generating a treatment plan for the patient.
B. To interpret this action as an indication that the client is finished with the conversation
assuming that the client has completed her conversation is incorrect since it is an opportunity to explore the client’s feelings and thoughts that may be missed.
C. To ask the client a question so the interaction can continue
this is not the best action since it may interrupt the client’s natural process of reflection and expression while pressuring him/her to respond to the questions asked.
D. To remain silent and be attentive to the client's nonverbal communication
remaining silent and being attentive to the client’s nonverbal communication shows respect for the client’s pace and readiness to speak. Furthermore, it demonstrates the nurse’s presence and their support.
Full Explanation
Choice A rationale: this may imply that the client is not cooperating and may make them feel guilty thus discouraging any further communication which may be useful in generating a treatment plan for the patient.
Choice B rationale: assuming that the client has completed her conversation is incorrect since it is an opportunity to explore the client’s feelings and thoughts that may be missed.
Choice C rationale: this is not the best action since it may interrupt the client’s natural process of reflection and expression while pressuring him/her to respond to the questions asked.
Choice D rationale: remaining silent and being attentive to the client’s nonverbal communication shows respect for the client’s pace and readiness to speak.
Furthermore, it demonstrates the nurse’s presence and their support.
A client is on Clozaril (Clozapine). The nurse is aware that frequent blood work is essential during the first 6 months of treatment to monitor for the presence of what?
A. A decrease in white blood cells
Clozapine is an antipsychotic medication associated with agranulocytosis which is a condition where the bone marrow does not provide enough white blood cells. This increases an individual’s risk of infections. Therefore, frequent blood tests should be performed on an individual taking this medication to monitor the WBC count and stop the medication if need be.
B. A low hemoglobin levels
clozapine is not associated with a low hemoglobin level. Anemia may be caused by conditions such as iron deficiency, chronic conditions such as chronic kidney disease, and vitamin B12 deficiency.
C. An increase in white blood cells
An increase in white blood cell count is not a side effect of clozapine but can be caused by infections. Clozapine causes low white blood cell count.
D. Blood in the urine
blood in urine is not a side effect of clozapine but can be caused by the use of medications such as cyclophosphamide.
Full Explanation
Choice A rationale: Clozapine is an antipsychotic medication associated with agranulocytosis which is a condition where the bone marrow does not provide enough white blood cells. This increases an individual’s risk of infections. Therefore, frequent blood tests should be performed on an individual taking this medication to monitor the WBC count and stop the medication if need be.
Choice B rationale: clozapine is not associated with a low hemoglobin level. Anemia may be caused by conditions such as iron deficiency, chronic conditions such as chronic kidney disease, and vitamin B12 deficiency.
Choice C rationale: An increase in white blood cell count is not a side effect of clozapine but can be caused by infections. Clozapine causes low white blood cell count.
Choice D rationale: blood in urine is not a side effect of clozapine but can be caused by the use of medications such as cyclophosphamide.