A client has been taking an antipsychotic medication for several years. It is of vital importance for the nurse to observe the client for tardive dyskinesia. Signs and symptoms of tardive dyskinesia include:
Absence of physical and mental movement
Loss of ability to perform voluntary movements
Repetitious, involuntary muscle movements in the face and extremities
Rigidity in the muscles that control an individual's gait, posture, and eye movements
The Correct Answer is C
Choice A rationale: absence of physical and mental movement refers to catatonia that can occur in severe depression or schizophrenia.
Choice B rationale: akinesia refers to the absence of voluntary movement and can be seen in individuals with Parkinson’s disease or as a side effect of some antipsychotic medications.
Choice C rationale: these are signs and symptoms of tardive dyskinesia which is a serious side effect of antipsychotic therapy resulting from the damage of nerve cells controlling movement and is irreversible especially when detected late.
Choice D rationale: this refers to dystonia which is a condition characterized by abnormal muscle tone resulting in painful muscle spasms and abnormal postures. This is a side effect of some antipsychotic medications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
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.
Correct Answer is C
Explanation
Choice A rationale: Excessive noise does impact the professional environment, but the primary concern is its potential impact on clients rather than the appearance of the mental health unit.
Choice B rationale: Excessive noise is more likely to disturb clients by causing insomnia and irritability rather than promoting relaxation.
Choice C rationale: Excessive noise in a mental health unit can disrupt the therapeutic environment and interfere with clients' thinking processes and perceptions by triggering anxiety, aggression, and anxiety. Therefore, maintaining a calm and quiet atmosphere supports mental health treatment.
Choice D rationale: There is no indication that excessive client noise is encouraged by the staff. However, the main concern is the impact of the staff noise on clients.
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