A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? (Select all that apply.)

Fine hand tremors and pill rolling

Urinary retention and constipation

Facial grimacing and eye blinking

Involuntary pelvic rocking and hip thrusting movements

Tongue thrusting and lip-smacking:

Answer and Explanation

Correct Answer : C,D,E

Fine hand tremors and pill rolling are not indicative of tardive dyskinesia. These symptoms are more commonly associated with other neurological or movement disorders.

B. Urinary retention and constipation:

Urinary retention and constipation are not symptoms of tardive dyskinesia. These symptoms are more related to anticholinergic effects of certain medications.

C. Facial grimacing and eye blinking:

Facial grimacing and repetitive, involuntary movements such as eye blinking are characteristic of tardive dyskinesia. These abnormal movements of the face and eyes are commonly seen in individuals who have been on long-term antipsychotic medications, especially older ones like haloperidol.

D. Involuntary pelvic rocking and hip thrusting movements:

TD often includes repetitive, purposeless movements of the limbs, trunk, and pelvis.

E. Tongue thrusting and lip-smacking:

Tongue thrusting and lip-smacking are classic symptoms of tardive dyskinesia. These repetitive, involuntary movements involving the mouth and tongue are often observed in individuals who have been on antipsychotic medications for an extended period of time.

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Correct Answer is B

Explanation

A. Tactile hallucination: Incorrect

Tactile hallucinations involve false sensations of touch, such as feeling something on the skin that isn't there. While these hallucinations can be distressing, they are not typically considered a priority over other types of hallucinations, especially those that might pose more immediate risks.

B. Command hallucination: Correct

Command hallucinations involve hearing voices that command the individual to take specific actions, often harmful ones. These types of hallucinations are considered a significant priority because they can lead to dangerous behaviors, self-harm, or harm to others. Addressing and managing command hallucinations promptly is crucial to ensure the safety of the individual and those around them.

C. Visual hallucination: Incorrect

Visual hallucinations involve seeing things that aren't actually present. While these can be distressing, they are generally considered less urgent compared to command hallucinations, which can directly lead to risky actions.

D. Gustatory hallucination: Incorrect

Gustatory hallucinations involve false perceptions of taste. While these can be unsettling, they are not typically considered a priority over command hallucinations, which have a more immediate potential for harm.

A. A client runs 4 miles outdoors every afternoon. B. The client eats 2 to 3 gm of sodium-containing foods daily. C. The client drinks 2 liters of liquids daily. D. The client eats foods high in tyramine.

Correct Answer is A

Explanation

A.Lithium is excreted through the kidneys, and dehydration and sodium depletion increase the risk of lithium toxicity. A client who runs 4 miles outdoors every afternoon is at risk of excessive sweating and fluid loss, which can lead to dehydration and sodium depletion. This reduces lithium excretion, leading to toxic levels in the blood.

B. Anormal sodium intake helps maintain lithium balance. A low sodium intake increases lithium retention, but 2-3 grams/day is within the normal recommended range.

C. Adequate hydration helps prevent lithium toxicity. Clients on lithium should drink 2–3 liters of fluid daily to promote kidney function and lithium excretion.
D. Tyramine-rich foods (e.g., aged cheese, cured meats) are a concern for clients on monoamine oxidase inhibitors (MAOIs), not lithium. Tyramine does not affect lithium levels.

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A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has schizophrenia and is experiencing a variety of hallucinations. Which of the following hallucinations is the priority for the nurse to address?

Correct Answer is B

Explanation

A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse could teach the client which of the following factors puts her at risk for lithium toxicity?

Correct Answer is A

Explanation

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