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 B
Explanation
Choice A rationale: this is incorrect since it is not sufficient by itself to warrant an inpatient admission hence the client can be managed as an outpatient.
Choice B rationale: this is one of the criteria for inpatient admission to a mental health facility since with the inability to cope with life stressors or control his behaviors the patient is at risk of harming either themselves or others. Moreover, this criterion reflects the principle of beneficence, meaning that the best is being done for the client's well-being and safety.
Choice C rationale: this is incorrect since depression is not sufficient by itself to warrant an inpatient admission hence the client can be managed as an outpatient.
Choice D rationale: this is incorrect since it is not sufficient by itself to warrant an inpatient admission hence the client can be managed as an outpatient.
Correct Answer is D
Explanation
Choice A rationale: Clozapine has no effect on a patient’s blood pressure levels. However, blood pressure monitoring for all patients is crucial but the temperature is more relevant for a patient on clozapine.
Choice B rationale: Clozapine has no effect on an individual’s respiratory rate hence in this case it is not the priority vital sign to monitor.
Choice C rationale: Clozapine use does not cause pain. Furthermore, pain is not a vital sign.
Choice D rationale: One of the side effects of clozapine is agranulocytosis hence this predisposes the patient to infections which may manifest with fever. Therefore, it is important to monitor the patient’s temperature while on treatment.
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