A nurse is assessing a client diagnosed with schizophrenia, which has been treated with fluphenazine (Prolixin) for several years. Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?

Twisting tongue movements.

Constant tapping of feet when sitting.

Shuffling gait.

Sudden onset of high fever.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Twisting tongue movements are characteristic manifestations of tardive dyskinesia (TD). TD is a movement disorder associated with long-term use of antipsychotic medications like fluphenazine (Prolixin). These involuntary movements often involve the face and tongue and can be irreversible if not addressed promptly.

Choice B rationale:

Constant tapping of feet when sitting is not a typical manifestation of tardive dyskinesia. This type of movement might be related to restlessness or anxiety, but it is not specifically associated with the movement disorder caused by prolonged antipsychotic use.

Choice C rationale:

Shuffling gait can be associated with parkinsonism, which is another potential adverse effect of antipsychotic medications, including fluphenazine. However, for tardive dyskinesia, the characteristic movements are more often related to the face and mouth rather than the legs and gait.

Choice D rationale:

Sudden onset of high fever is not a manifestation of tardive dyskinesia. It could potentially be a sign of a different medical issue, such as an infection. However, it is not directly related to the movement disorder caused by long-term antipsychotic use.

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Correct Answer is D

Explanation

Choice A rationale:

"This is supposed to happen when you get old, right?" is a common misconception but doesn't necessarily support the diagnosis of delirium. It could be attributed to normal aging changes.

Choice B rationale:

"Since his mother died, he has not been feeling well." indicates a potential stressor but doesn't directly address the rapid onset of behavioral changes, which is a hallmark of delirium.

Choice C rationale:

"My husband just didn't seem to know what he was doing. He has been forgetful for years." suggests a history of forgetfulness rather than an acute change in behavior, which is more indicative of chronic cognitive issues like dementia.

Choice D rationale:

(Correct) "The changes in his behavior came on so quickly! I wasn't sure what was happening." This statement supports the diagnosis of delirium, which is characterized by a sudden onset of confusion and changes in cognitive function. Delirium often develops rapidly, and the client's wife's observation aligns with this diagnostic criterion.

A. "I need to identify things that cause me to be an alcoholic." B. "I am powerless against my addiction to alcohol." C. "I am responsible for my alcoholism." D. "I need to see a counselor who will be responsible for my recovery.".

Correct Answer is B

Explanation

The correct answer is choice B: "I am powerless against my addiction to alcohol."

Choice B rationale:

This statement reflects an understanding of one of the fundamental principles of Alcoholics Anonymous (AA), which is the acknowledgment of powerlessness over alcohol. The concept of powerlessness is a cornerstone of the 12-step program and encourages individuals to recognize that attempting to control their addiction often leads to negative consequences. This admission is crucial for clients in recovery, as it opens the door to seeking support and relying on the fellowship and guidance of AA.

Choice A rationale:

While identifying triggers for alcoholism is important, this statement does not directly capture the essence of AA's principle. The focus on identifying causes does not fully encompass the concept of powerlessness over the addiction.

Choice C rationale:

Responsibility for one's alcoholism is not a core principle of AA. Instead, the program encourages individuals to take responsibility for their actions and their commitment to recovery, but not for causing their addiction in the first place.

Choice D rationale:

AA is a peer support program that emphasizes personal responsibility and self-accountability. While counseling might be beneficial, the statement implies external responsibility for recovery, which contradicts the self-help nature of AA.

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A nurse is assessing a client diagnosed with schizophrenia, which has been treated with fluphenazine (Prolixin) for several years. Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A male client is admitted to the unit with a possible diagnosis of delirium. Which statement by the client's wife best supports the diagnosis?

Correct Answer is D

Explanation

A nurse is providing teaching to a client who has alcohol use disorder about Alcoholics Anonymous (AA). Which of the following client statements indicates an understanding of the program's basic concepts?

Correct Answer is B

Explanation

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