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?

Mental Status Examination

Brief Psychiatric Rating Scale

Patient Health Questionnaire-9

Abnormal Involuntary Movement Scale

Answer and Explanation

The Correct Answer is D

Answer: D. Abnormal Involuntary Movement Scale

Rationale: The Abnormal Involuntary Movement Scale is a diagnostic tool that assesses the severity of tardive dyskinesia, a disorder that results in involuntary repetitive body movements caused by long-term use of antipsychotic drugs.

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Correct Answer is C

Explanation

Choice A reason

Increased food intake does not show medication is effective: Increased food intake is not a specific indication of donepezil's effectiveness. While some clients with dementia may have improved appetite due to reduced agitation or confusion, it is not directly related to the medication's therapeutic effect.

Choice B reason:

Can perform ADLs independently is inappropriate: The ability to perform activities of daily living (ADLs) independently can be a positive outcome in clients with dementia. However, it may not be solely attributed to donepezil, as ADLs can be influenced by various factors, including the client's overall condition and support received.

Choice C reason:

Improved short-term memory is correct. One of the primary goals of using donepezil is to improve memory and slow the decline in cognitive abilities associated with dementia. Therefore, if a client shows improvement in short-term memory, it suggests that the medication is having a positive effect in preserving cognitive function.

Choice D reason

Enhanced mood does not show the medicine is effective: Donepezil is primarily aimed at improving cognitive function and memory, and its effects on mood may be limited. While some clients may experience mood improvements due to reduced frustration or confusion from memory loss, it is not the primary indicator of the medication's effectiveness

A. Fruity breath odor B. Clammy skin C. Bounding pulse D. Elevated blood pressure

Correct Answer is A

Explanation

The correct answer is A. Fruity breath odor. This is caused by the presence of acetone, a byproduct of fat metabolism, in the breath. Diabetic ketoacidosis is a condition where the body cannot use glucose as a fuel source due to insulin deficiency or resistance, and resorts to breaking down fat for energy, resulting in ketone production and acidosis. Clammy skin, bounding pulse and elevated blood pressure are signs of a hyperglycemic hyperosmolar state (HHS), another complication of diabetes that is characterized by severe dehydration and hyperglycemia without significant ketosis or acidosis.

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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

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is providing care for a client who has been receiving donepezil. Which of the following findings indicates that the medication is effective?

Correct Answer is C

Explanation

A nurse is collecting data from a client who has diabetic ketoacidosis. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is supervising an assistive personnel (AP) who is applying antiembolic stockings for a client. Which of the following actions by the AP requires intervention by the nurse?

A nurse is caring for a client who is receiving morphine for pain. Which of the following findings indicates that the client is experiencing an adverse effect of the medication?

A nurse on a medical-surgical unit is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?

A nurse is caring for a client who has a recent diagnosis of a terminal illness. The nurse should identify which of the following as an indication of hopelessness?

A nurse in an inpatient mental health facility is reinforcing teaching with a client who signed a consent form for electroconvulsive therapy. Which of the following statements by the clientindicates an understanding of the procedure?

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A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect?

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