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:

Attention-seeking conduct is not typically a manifestation of severe anxiety. While individuals may exhibit behaviors that draw attention in an attempt to alleviate their distress, it is not a direct symptom of anxiety itself. Attention-seeking may be associated with other psychological conditions or may be a response to feeling neglected or ignored.

Choice B reason:

Aggressive behavior can sometimes be seen in individuals with severe anxiety, particularly if they feel trapped or overwhelmed. However, it is not as common as other manifestations. Aggression may also stem from a variety of other factors, including personality disorders, mood disorders, or situational stressors, rather than anxiety alone.

Choice C reason:

Mild fidgeting is a common manifestation of severe anxiety. Anxiety can cause a surplus of energy and nervousness that manifests physically as fidgeting, such as tapping feet, playing with hands, or shifting positions frequently. This physical manifestation is a direct result of the body's fight-or-flight response, which prepares the individual to either confront or flee from perceived threats.

Choice D reason:

Mild difficulty problem-solving can occur in individuals with severe anxiety due to the overwhelming nature of their thoughts and feelings. Anxiety can disrupt cognitive processes, making it challenging to concentrate and think clearly. However, this is a broader cognitive effect of anxiety rather than a specific behavioral manifestation.

A. Have the client join a therapy group. B. Remain with the client in his room for a while. C. Suggest that the client rest in bed. D. Medicate the client with a sedative.

Correct Answer is B

Explanation

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.

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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

Naxlex Comprehensive Predictor Exams

What manifestations might a nurse at a walk-in mental health clinic recognize in a client experiencing severe anxiety?

Correct Answer is C

Explanation

A nurse on an inpatient mental health unit is admitting a client who has panic-level anxiety. After orienting the client to his room, which of the following nursing actions is most therapeutic at this time?

Correct Answer is B

Explanation

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