A nurse is caring for a client who has a serious mental illness and has developed tardive dyskinesia from anti-psychotic medication use. Which of the following adverse effects from anti-psychotic medication use would be expected for the client?

Uncontrolled movements around the mouth

Seizures and tremors

Nause And vomiting

Hallucinations and delusions

Answer and Explanation

The Correct Answer is A

A. Uncontrolled movements around the mouth.
Tardive dyskinesia is a side effect associated with the long-term use of antipsychotic medications, especially first-generation or typical antipsychotics. It is characterized by involuntary, repetitive movements, often involving the face, such as uncontrolled movements around the mouth (e.g., lip smacking, puckering, chewing).

B. Seizures and tremors are not typical adverse effects of tardive dyskinesia. They are more commonly associated with other side effects or conditions.

C. Nausea and vomiting are not typically associated with tardive dyskinesia. These symptoms may be side effects of antipsychotic medications, but they are not characteristic of tardive dyskinesia itself.

D. Hallucinations and delusions are not associated with tardive dyskinesia. Tardive dyskinesia primarily involves involuntary movements and is not related to changes in thought content or perception.

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Correct Answer is A

Explanation

A. Set limits on the amount of time the client talks about delusions.Clients with paranoid delusions may fixate on them, increasing distress and reinforcing their beliefs. The nurse should allow the client to express feelings but set limits on discussions about delusions to help refocus on reality-based topics.

B. Schedule a variety of competitive stimulating group activities for the client.Competitive activities can increase stress and paranoia in a client with schizophrenia. Instead, the nurse should encourage structured, low-stimulation activities like drawing or walking.

C. Tell the client that the delusions are not real. Directly challenging the delusions can increase defensiveness and mistrust.

D. Avoid asking the client about triggers for the delusions. Identifying triggers can help prevent or manage delusional episodes. The nurse should gently explore what makes the client feel more paranoid or anxious to develop coping strategies.

A. Exercising right before bed may help you to sleep better." B. Using alcohol for sleep can become problematic. Would you like to discuss other methods that might help you sleep"? C. A glass of wine in the evening is a good way to take the edge off and help you to rest." D. You should speak with your provider about prescribing a sedative to help you sleep,

Correct Answer is B

Explanation

Explanation:
A. While exercise can be beneficial for promoting sleep, suggesting it right before bedtime may not be the most practical advice, as vigorous exercise close to bedtime can sometimes have the opposite effect.

B. "Using alcohol for sleep can become problematic. Would you like to discuss other methods that might help you sleep?"
This response acknowledges the potential issue with using alcohol as a sleep aid and opens the door for further discussion about alternative methods to promote better sleep. Alcohol can disrupt sleep patterns and lead to dependency, so it's important for the nurse to address this concern and explore healthier sleep-promoting strategies.

C. Encouraging the use of alcohol as a way to "take the edge off" is not the best approach, as it may reinforce the client's reliance on alcohol for sleep, which can lead to dependency and other health issues.

D. Suggesting that the client speak with their provider about prescribing a sedative should not be the initial response. It's essential to explore non-pharmacological interventions and lifestyle changes before considering medications, especially sedatives, due to the potential for dependence and side effects.

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A nurse is caring for a client who has a serious mental illness and has developed tardive dyskinesia from anti-psychotic medication use. Which of the following adverse effects from anti-psychotic medication use would be expected for the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute care mental health facility is contributing to the plan of care for a client who is newly diagnosed with schizophrenia and is verbalizing paranoid delusions. Which of the following interventions should the nurse include in the plan?

Correct Answer is A

Explanation

A nurse is assisting in the care of a client who has chronic stress. The client states. i always feel so tired, but I can't sleep unless I have a cocktail or glass of wine at bedtime." Which of the following responses should the nurse make?

Correct Answer is B

Explanation

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