A client is receiving benztropine mesylate for drug-induced extrapyramidal syndrome (EPS). Which finding indicates that the nurse should further evaluate the client?

Choice A reason: Involuntary foot tapping suggests tardive dyskinesia, a side effect of long-term antipsychotic use. Documenting on the Abnormal Involuntary Movement Scale (AIMS) quantifies and tracks this movement disorder, aiding provider evaluation, aligning with psychopharmacology monitoring protocols, making it the correct additional action.

Choice B reason: Advising about medication tolerance is incorrect, as foot tapping indicates tardive dyskinesia, not tolerance. Tolerance implies reduced drug efficacy, not movement disorders. Documentation on AIMS is needed to assess this side effect, making this choice inappropriate for addressing the observed symptom.

Choice C reason: Foot tapping is likely tardive dyskinesia, not an anxiety manifestation. Assisting with anxiety recognition misattributes the symptom, delaying proper evaluation. Documenting on AIMS ensures accurate assessment of antipsychotic side effects, making this incorrect for the nurse’s additional action in this scenario.

Choice D reason: Seizure precautions are unwarranted, as foot tapping suggests tardive dyskinesia, not seizures. Antipsychotics rarely cause seizures, and this movement is non-epileptic. Documenting on AIMS is the appropriate action to evaluate this side effect, making seizure precautions incorrect and unnecessary.

Choice A reason: Decreased bowel movements (constipation) are a common side effect of benztropine due to its anticholinergic properties, but they do not indicate worsening EPS or treatment failure. Increased mouth movements suggest persistent or worsening EPS, requiring further evaluation, making constipation less critical for immediate reassessment.

Choice B reason: Decreasing hand tremors indicate benztropine’s effectiveness in treating EPS, as it reduces parkinsonian symptoms like tremors. This is a desired outcome, not a cause for further evaluation. Increased mouth movements, suggesting tardive dyskinesia or EPS persistence, are more concerning, making this incorrect.

Choice C reason: Increased mouth movements, such as tardive dyskinesia or dystonia, suggest worsening or inadequately controlled EPS, potentially indicating benztropine’s ineffectiveness or a need for dose adjustment. This finding warrants further evaluation, aligning with psychopharmacology evidence for monitoring anticholinergic therapy, making it the correct choice.

Choice D reason: Dry mouth is a common anticholinergic side effect of benztropine, not an indicator of EPS worsening. It is expected and manageable, unlike increased mouth movements, which signal potential EPS complications. This finding does not require immediate evaluation, making it incorrect for further nursing assessment.