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 ["B","C","D","E"]
Explanation
Answer: (B, C, D, E)
Rationale:
A) Damp dressing: A damp dressing around the IV site is typically indicative of a leaking IV or infiltration, where fluid escapes from the vein into the surrounding tissue. This finding is not directly related to phlebitis, which is inflammation of the vein.
B) Warmth at insertion site: Warmth at the insertion site is a common sign of phlebitis. The inflammation of the vein causes increased blood flow to the area, leading to localized warmth. This symptom is a key indicator that the IV site may be irritated or infected.
C) Streak formation: Streak formation, often seen as a red line running along the vein above the IV site, is a classic sign of phlebitis. It indicates inflammation and irritation spreading along the vein, which can occur due to the presence of the IV catheter.
D) Throbbing: Throbbing pain or discomfort at the IV site is another sign of phlebitis. The inflammation of the vein can cause pain that may be constant or increase with movement or palpation, indicating irritation or potential damage to the vessel.
E) Erythema: Erythema, or redness at the IV site, is a hallmark sign of phlebitis. The inflammation results in redness around the insertion area, which may spread along the vein, further indicating the presence of irritation or infection at the site.
Correct Answer is A
Explanation
Alprazolam is a benzodiazepine medication commonly used to treat anxiety and insomnia. Here's the rationale for each option:
A. "Avoid activities that require alertness, such as driving.": Alprazolam can cause drowsiness and impair cognitive function, so it's essential for clients to avoid activities that require alertness, such as driving or operating heavy machinery, while taking this medication. Providing this instruction promotes safety and prevents accidents.
B. "Monitor for peripheral edema.": Peripheral edema is not a common side effect of alprazolam. This instruction is not relevant to the use of this medication.
C. "Take this medication with a high-fat meal.": Alprazolam can be taken with or without food, but taking it with a high-fat meal may delay its absorption. Therefore, it is not necessary to instruct the client to take it with a high-fat meal, especially since this may affect the medication's effectiveness.
D. "Take this medication every night before sleep.": While alprazolam may be used to treat insomnia, it is not typically recommended for nightly use due to the risk of dependence and tolerance. Using it nightly can lead to addiction and withdrawal symptoms if abruptly stopped. Therefore, this instruction is not appropriate.
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