A nurse is collecting data from a client who has schizophrenia and has been taking chlorpromazine for 8 years. The nurse notes choreiform or jerking uncontrolled movements, lip smacking, and spastic facial distortions. Which of the following conditions should the nurse document in her finding?

Tardive dyskinesia

Lock Jaw (unable to close mouth)

Pseudoparkinsonism

Akathisia

Answer and Explanation

The Correct Answer is A

A.   Tardive dyskinesia is a movement disorder often caused by long-term use of antipsychotic medications like chlorpromazine. Symptoms include involuntary movements such as jerking or lip smacking.
B.   Lock Jaw is not a characteristic of tardive dyskinesia; it refers to trismus, often seen with other conditions.
C.   Pseudoparkinsonism is characterized by tremors, rigidity, and bradykinesia, typically occurring early in antipsychotic treatment.
D.   Akathisia involves restlessness and an inability to stay still, not the involuntary movements associated with tardive dyskinesia.

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Correct Answer is C

Explanation

A. This statement suggests dependency and a lack of readiness to take responsibility for self-care.
B. While family support is important, the client should be able to demonstrate some level of independence for discharge readiness.
C. Taking medications as prescribed and knowing who to contact in case of suicidal thoughts shows insight and preparedness for discharge.
D. This statement reflects avoidance and a lack of motivation, indicating that the client is not yet ready for discharge.

A. check the patient's record to determine his baseline blood pressure. B. notify the charge nurse of the hypotension. C. check medications that might be the cause of the irregularity. D. notify the doctor of the bradycardia.

Correct Answer is A

Explanation

A. Checking the patient's baseline blood pressure helps to determine if the current reading of 98/66 mm Hg is normal for them or if it represents a significant change.
B. This may not be necessary if the blood pressure is normal for the patient. Hypotension is relative, and what is considered low for one person might be normal for another.
C. While this is a good practice, it should be done after determining if there is a significant change from the baseline. The irregular pulse could be due to various factors, including medications, but the first step is to understand the patient's normal range.
D. The patient's pulse is 76 beats/min, which is not bradycardic (bradycardia is defined as a heart rate less than 60 beats/min). Therefore, notifying the doctor of bradycardia is not appropriate in this case.

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A nurse is collecting data from a client who has schizophrenia and has been taking chlorpromazine for 8 years. The nurse notes choreiform or jerking uncontrolled movements, lip smacking, and spastic facial distortions. Which of the following conditions should the nurse document in her finding?

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Naxlex Comprehensive Predictor Exams

A nurse assisting in the care of a client who has a mood disorder. Which of the following client statements by the client indicates readiness for discharge?

Correct Answer is C

Explanation

A 45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular). The best nursing intervention is to:

Correct Answer is A

Explanation

A nurse is contributing to the plan of care for a client who has severe depression following the loss of her spouse. When identifying client goals, which of the following goals should the nurse identify as the highest priority?

If a silence is heard between sounds when auscultating blood pressure, it is termed a(n)

A nurse is collecting data from a client who has schizophrenia and has been taking chlorpromazine for 8 years. The nurse notes choreiform or jerking uncontrolled movements, lip smacking, and spastic facial distortions. Which of the following conditions should the nurse document in her finding?

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