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)?

Sudden onset of high fever

Twisting tongue movements

Constant tapping of feet when sitting

Shuffling gait

Answer and Explanation

The Correct Answer is B

Choice A reason:

A sudden onset of high fever is not a symptom of tardive dyskinesia (TD). High fever may indicate an infection or other serious conditions such as neuroleptic malignant syndrome, which is a different and more severe reaction to antipsychotic medications

Choice B reason:

Twisting tongue movements are a classic sign of tardive dyskinesia. TD is characterized by repetitive, involuntary, and purposeless movements that often affect the face, including the tongue. These movements result from long-term use of certain antipsychotic medications, like fluphenazine, which block dopamine receptors in the brain.

Choice C reason:

Constant tapping of the feet when sitting could be a sign of restlessness or akathisia, which is another side effect of antipsychotic medications but is not specifically indicative of tardive dyskinesia. TD typically involves more complex movements of the limbs, not just simple tapping.

Choice D reason:

A shuffling gait is more commonly associated with parkinsonism or pseudoparkinsonism, which can also be a side effect of antipsychotic medications. It is not a typical manifestation of tardive dyskinesia, which usually presents with involuntary movements of the face, tongue, and upper body

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Correct Answer is C

Explanation

Choice A Reason:

An internal crisis refers to a psychological conflict that arises within the individual, often related to unresolved issues from the past. This type of crisis is not typically triggered by external events but rather by internal struggles and can manifest as mental health issues such as depression or anxiety. In this scenario, the client's denial of the HIV diagnosis does not necessarily indicate an internal crisis but rather a reaction to a specific event.

Choice B Reason:

Maturational crises are associated with life transitions or developmental stages, such as adolescence, midlife, or retirement. These crises are part of normal growth and development. The client's situation does not fit this category, as it is not related to a natural stage of life but rather to the diagnosis of a health condition.

Choice C Reason:

A situational crisis occurs when an external event that is unexpected or unanticipated disrupts an individual's life. The diagnosis of HIV is a life-altering event that can lead to a situational crisis, as it presents a significant challenge to the client's sense of normalcy and can trigger a strong emotional response, such as denial.

Choice D Reason:

Adventitious crises are large-scale events that affect communities or societies, such as natural disasters, terrorist attacks, or pandemics. These crises are not personal in nature and are not the result of an individual's life circumstances. The client's denial of his HIV diagnosis does not constitute an adventitious crisis.

A. Impulsive behaviors B. Sleeping for long periods of time C. Interacting with others in a flirtatious way D. Dressing in black or grey clothing E. Talking in rapid, continuous speech

Correct Answer is ["A","C","E"]

Explanation

Choice A Reason:

Impulsive behaviors are a hallmark of manic episodes in bipolar disorder. During mania, individuals often exhibit poor judgment and engage in risky activities without considering the consequences. This can include spending sprees, reckless driving, or making hasty decisions.

Choice B Reason:

Sleeping for long periods of time is more indicative of a depressive episode rather than a manic episode. During mania, individuals typically experience decreased need for sleep and may feel energized despite getting very little rest.

Choice C Reason:

Interacting with others in a flirtatious way is a common behavior during manic episodes. Individuals may exhibit increased sociability, hypersexuality, and inappropriate or provocative behavior. This heightened sociability and flirtatiousness are often out of character for the individual when they are not experiencing mania.

Choice D Reason:

Dressing in black or grey clothing is not specifically associated with manic behavior. While changes in appearance can occur during mood episodes, the color of clothing is not a reliable indicator of mania. Manic episodes are more characterized by behaviors and mood changes rather than specific clothing choices.

Choice E Reason:

Talking in rapid, continuous speech, also known as pressured speech, is a classic symptom of mania. Individuals may speak quickly, loudly, and incessantly, making it difficult for others to interrupt or follow the conversation. This symptom reflects the heightened energy and racing thoughts typical of manic episodes.

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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)?

Nursing Test Bank

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Correct Answer is C

Explanation

A nurse is caring for a client who has bipolar disorder. Which of the following actions by the client should the nurse interpret as displaying manic behavior? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

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