A nurse is assessing a client who has schizophrenia which has been treated with fluphenazine for several years.
Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?.
Twisting tongue movements.
Shuffling gait.
Sudden onset of high fever.
Constant tapping of feet when sitting.
The Correct Answer is A
Choice A rationale:
Twisting tongue movements are a common symptom of tardive dyskinesia (TD), a side effect of long-term use of antipsychotic medications like fluphenazine.
Choice B rationale:
Shuffling gait is more commonly associated with Parkinson’s disease and certain antipsychotic medications can cause Parkinson-like symptoms, but it is not a characteristic of TD2.
Choice C rationale:
Sudden onset of high fever is not associated with TD. It could be a sign of a serious condition like neuroleptic malignant syndrome, which requires immediate medical attention.
Choice D rationale:
Constant tapping of feet when sitting could be a sign of restlessness or akathisia, another potential side effect of antipsychotic medications, but it is not a specific sign of TD2.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
While educating the client about policies upon admission to the unit is important, it may not have the greatest impact on both the management of care and on milieu environment.
Choice B rationale:
Instructing the client that intrusive behaviors are not appropriate is important, but it may not have the greatest impact on both the management of care and on milieu environment.
Choice C rationale:
Ensuring that the client’s medication therapy is administered in a timely manner is crucial, but it may not have the greatest impact on both the management of care and on milieu environment.
Choice D rationale:
Setting and maintaining consistent unit policies that are enforced by all staff can create a stable and predictable environment, which can have a significant impact on both the management of care and on milieu environment.
Correct Answer is B
Explanation
Choice A rationale:
Asking why the client feels they will never get better might come across as dismissive or confrontational.
Choice B rationale:
This response acknowledges the client’s feelings and offers a supportive approach to managing the symptoms of somatic symptom disorder. This disorder is characterized by a significant focus on physical symptoms that cause major distress and/or problems functioning. The main treatment is psychotherapy, and medication might be given in some cases.
Choice C rationale:
Focusing only on the physical symptoms might not address the emotional distress that the client is experiencing.
Choice D rationale:
While it’s important to offer hope, this response might come across as dismissive of the client’s current feelings.
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