A nurse is caring for a client who has schizophrenia and is taking an antipsychotic medication. Which of the following screening tools should the nurse use to identify tardive dyskinesia?

Patient Health questionnaire 9

Mental Status Examination

Brief Psychiatric Rating Scale

Abnormal Involuntary Movement Scale

Answer and Explanation

The Correct Answer is D

A.   Incorrect. The Patient Health questionnaire is used to assess depression severity.
B.   Incorrect. The Mental Status Examination assesses cognitive function and psychiatric symptoms.
C.   Incorrect. The Brief Psychiatric Rating Scale assesses psychiatric symptoms but not specifically tardive dyskinesia.
D.   Correct. The Abnormal Involuntary Movement Scale (AIMS. is specifically designed to screen for and assess the severity of tardive dyskinesia, which is a movement disorder associated with antipsychotic medications.

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Correct Answer is B

Explanation

A. Incorrect. Offering to watch television may not address the client's agitation and anxiety effectively.
B. Correct. The client's behaviors suggest anxiety or agitation. Using short, simple sentences when speaking with the client can help reduce their stress and facilitate communication.
C. Incorrect. While some clients may benefit from alone time, it's important to assess the client's preferences and needs. Isolating the client in their room might not be the best approach if they are seeking engagement.
D. Incorrect. Moving the client to a group setting may increase their discomfort or agitation. It's important to consider the client's current emotional state and tailor interventions accordingly.

A. Limit the client's social interactions. B. Encourage the client to be assertive. C. Assume responsibility for making the client's decisions. D. Maintain a verbal no-harm contract with the client.

Correct Answer is B

Explanation

A. Incorrect. Limiting the client's social interactions would not be helpful and might further exacerbate feelings of dependence.
B. Correct. Encouraging the client to be assertive is an important aspect of promoting independence and self-advocacy. Clients with dependent personality disorder may struggle with asserting themselves, and fostering assertiveness can improve their overall well-being.
C. Incorrect. Assuming responsibility for making the client's decisions would reinforce their dependence, which is not the goal of treatment.
D. Incorrect. Maintaining a verbal, no-harm contract is typically used for clients at risk of self-harm or harm to others and is not directly related to addressing the challenges of dependent personality disorder.

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A nurse is caring for a client who has schizophrenia and is taking an antipsychotic medication. Which of the following screening tools should the nurse use to identify tardive dyskinesia?

Nursing Test Bank

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