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 D

Explanation

The nurse should observe the client using the glucometer to assess their technique and accuracy. This is an example of a return demonstration, which is an effective teaching method for psychomotor skills.

A. Re-evaluate the client for an ET cuff leak. B. Assess for disconnected tubing. C. Decrease the ventilator flow rate. D. Deliver breaths manually with a resuscitation bag.

Correct Answer is D

Explanation

Choice A reason

Re-evaluate the client for an ET cuff leak is not appropriate. While an ET cuff leak could contribute to respiratory distress, the immediate concern is the high-pressure alarm, which indicates increased resistance to airflow. The nurse should address the alarm first and then assess for other potential causes, including an ET cuff leak.

Choice B reason:

Option B: Assess for disconnected tubing is not appropriate. A disconnected tubing is also a potential cause of the high-pressure alarm. However, before checking for disconnected tubing, the nurse should first deliver manual breaths with a resuscitation bag to provide the client with adequate ventilation.

Choice C reason:

Decrease the ventilator flow rate is not appropriate. Decreasing the ventilator flow rate might not be the appropriate action in this situation, as the high-pressure alarm indicates increased resistance, which might require increased flow to overcome. Additionally, the nurse should not delay taking immediate action by adjusting ventilator settings without knowing the specific cause of the high-pressure alarm.

Choice D reason:

When the high-pressure alarm is beeping, and the client is experiencing respiratory distress, it indicates that there is an increased resistance to airflow within the ventilator circuit or the client's airway. This can be a life-threatening situation, and immediate action is required.

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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?

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Naxlex Comprehensive Predictor Exams

A home health nurse is reinforcing teaching with a client who has diabetes mellitus. Which of the following statements should the nurse make to evaluate the client's use of a glucometer?

Correct Answer is D

Explanation

A nurse is caring for a client receiving mechanical ventilation via an endotracheal (ET) tube. The high-pressure alarm is beeping, and the client is experiencing respiratory distress. The nurse is unable to determine the cause of the alarm. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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