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

Choice A Reason:

Having the client join a therapy group immediately after admission is not the most therapeutic action for someone experiencing panic-level anxiety. Group settings can be overwhelming and may exacerbate the client's anxiety. It is important to first stabilize the client's anxiety before introducing them to group therapy.

Choice B Reason:

Remaining with the client in his room for a while is the most therapeutic action. This approach provides a calming presence and helps the client feel safe and supported. It allows the nurse to assess the client's anxiety level and offer immediate reassurance. Being present with the client can help reduce feelings of isolation and panic, creating a more stable environment for the client to begin to calm down.

Choice C Reason:

Suggesting that the client rest in bed may not be effective for someone with panic-level anxiety. While rest is important, the client may be too anxious to relax or sleep. Without addressing the immediate anxiety, simply suggesting rest may not provide the necessary support the client needs at that moment.

Choice D Reason:

Medicating the client with a sedative should be considered only after other non-pharmacological interventions have been attempted. While sedatives can help reduce anxiety, they should not be the first line of action. It is important to try to calm the client through therapeutic presence and reassurance before resorting to medication.

Choice A reason: Verbalizing disapproval of the client’s substance abuse is not therapeutic and can harm the nurse-client relationship. It may cause the client to feel judged and less likely to be open about their struggles, hindering the treatment process.

Choice B reason: While it is important to maintain professionalism, avoiding any emotional response can make the nurse seem distant and uncaring. A balance between empathy and professional detachment is necessary to build rapport and trust with the client.

Choice C reason: Maintaining a nonjudgmental attitude is essential in the therapeutic setting, especially during the initial interview at an alcohol treatment center. It helps to create a safe environment where the client feels respected and understood, which can facilitate openness and honesty about their issues with substance abuse.

Choice D reason: Offering sympathetic support is a positive approach, but it must be carefully balanced with professional boundaries. Sympathy can sometimes be mistaken for pity, which might not be empowering for the client. Empathy, which involves understanding and sharing the feelings of another, is generally more appropriate in a therapeutic setting.