A nurse is assessing a client who has schizophrenia and has been on long-term treatment with chlorpromazine. He notes the client is experiencing some involuntary movements of the tongue and face. The nurse should suspect the client has developed which of the following adverse effects?
Dystonia
Tardive dyskinesia
Parkinsonism
Akathisia
The Correct Answer is B
A. Dystonia - Dystonia presents as sustained or intermittent muscle contractions causing abnormal, often repetitive, movements or postures. It is an acute extrapyramidal side effect of antipsychotic medications like chlorpromazine but typically manifests as sudden-onset muscle spasms rather than involuntary movements of the tongue and face.
B. Tardive dyskinesia - Tardive dyskinesia is a late-appearing movement disorder characterized by involuntary, repetitive movements of the face, tongue, and limbs. It is associated with long-term use of antipsychotic medications like chlorpromazine and typically develops after months to years of treatment.
C. Parkinsonism - Parkinsonism resembles Parkinson's disease and is characterized by symptoms such as tremor, rigidity, bradykinesia, and postural instability. While antipsychotic medications can cause Parkinsonism as an adverse effect, it usually presents with symptoms different from those described in the scenario.
D. Akathisia - Akathisia is characterized by an inner feeling of restlessness and the urge to move, often accompanied by pacing and inability to sit still. It is an acute extrapyramidal side effect of antipsychotic medications but does not manifest as involuntary movements of the tongue and face as described in the scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The client drinks 2 liters of liquids daily. - This statement indicates adequate fluid intake, which is important for preventing dehydration and lithium toxicity. Increased fluid intake helps maintain normal lithium levels by promoting its excretion through urine.
B. The client eats 2 to 3 gm of sodium-containing foods daily. - This statement suggests a moderate sodium intake, which can help maintain stable lithium levels. Adequate sodium intake is important for preventing lithium toxicity because sodium depletion can increase lithium reabsorption by the kidneys, leading to higher serum levels.
C. The client runs 4 miles outdoors every afternoon. - This statement indicates excessive sweating, which can lead to dehydration and subsequent lithium toxicity. Vigorous exercise, particularly in hot environments, increases fluid loss through sweating, potentially reducing lithium excretion and increasing serum levels.
D. The client eats foods high in tyramine. - This statement is unrelated to lithium toxicity. Tyramine-containing foods are typically associated with interactions with monoamine oxidase inhibitors (MAOIs), not lithium.
Correct Answer is D
Explanation
A. Hold the injection if seizure activity is present:
This is incorrect. Phenytoin is an antiepileptic medication used to prevent seizures. If a client with a seizure disorder is experiencing seizure activity, it is essential to administer phenytoin promptly to help control and prevent further seizures.
B. Administer the medication at 100 mg/min:
This is incorrect. Phenytoin should be administered at a rate no faster than 50 mg/min to reduce the risk of adverse effects such as hypotension, arrhythmias, and cardiovascular collapse. Rapid infusion can cause adverse reactions such as hypotension, bradycardia, and cardiac arrhythmias.
C. Dilute the medication with dextrose 5% in water:
This is incorrect. Phenytoin should not be diluted with dextrose-containing solutions, as it can cause precipitation and result in clogging of the IV line. It is typically administered undiluted or diluted with normal saline solution.
D. Administer a saline solution after injection:
This is the correct action. After administering phenytoin IV, it is recommended to flush the IV line with normal saline solution to ensure that the medication is fully delivered and to prevent any remaining medication from precipitating in the IV line, which could lead to occlusion.
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