A nurse is collecting data from a client who has schizophrenia and is taking fluphenazine. The nurse observes that the client’s tongue is protruding and he has irregular movements of his limbs. The nurse should identify that the client is exhibiting manifestations of which of the following?

A reaction to drinking grapefruit juice with the medication.

Early symptoms of tardive dyskinesia.

Missing a dose of the medication.

Early symptoms of a psychotic episode.

Answer and Explanation

The Correct Answer is B

Choice A reason: Grapefruit juice can interact with certain medications, particularly those metabolized by the cytochrome P450 system, but fluphenazine is not significantly affected by grapefruit juice. The symptoms described tongue protrusion and irregular limb movements are not related to food-drug interactions but rather to neurological side effects.

Choice B reason: The protrusion of the tongue and irregular limb movements are hallmark early signs of tardive dyskinesia, a serious extrapyramidal side effect of long-term antipsychotic use. Tardive dyskinesia involves involuntary, repetitive movements, often of the face, tongue, and extremities. Identifying these symptoms early is crucial because tardive dyskinesia can become irreversible if not addressed promptly.

Choice C reason: Missing a dose of fluphenazine would more likely result in a return of psychotic symptoms rather than involuntary motor movements. The described symptoms are not consistent with medication noncompliance but rather with adverse effects of continued use.

Choice D reason: Early symptoms of a psychotic episode typically include hallucinations, delusions, disorganized thinking, or paranoia. Motor symptoms such as tongue protrusion and limb movements are not characteristic of psychotic relapse but are instead linked to medication side effects.

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Correct Answer is C

Explanation

Choice A reason: A stimulating environment may increase anxiety and worsen OCD symptoms. Clients with OCD benefit from calm, structured surroundings rather than overstimulation.

Choice B reason: Negative reinforcement is not appropriate in managing OCD. Punishing or discouraging ritualistic behavior can increase anxiety and worsen compulsions. Therapeutic approaches focus on support and gradual behavioral modification.

Choice C reason: Providing a structured schedule of activities helps reduce anxiety and provides predictability. Structure allows the client to engage in meaningful tasks, which can reduce time spent on compulsions and promote healthier coping strategies.

Choice D reason: Limiting rituals to a set time, such as 30 minutes daily, is not realistic or therapeutic in early care planning. Rituals should be addressed gradually with cognitive-behavioral therapy, not abruptly restricted, as sudden limits can heighten anxiety.

A. A client who has a family history of anxiety disorders and several positive childhood experiences (PCES). B. A client who did not graduate from high school or complete their general education development (GED) test. C. A client who has a family history of cancer and is recently unemployed. D. A client who had multiple adverse childhood experiences and whose parents both have a history of anxiety disorder.

Correct Answer is D

Explanation

Choice A reason: While family history of anxiety disorders is a risk factor, positive childhood experiences are protective and reduce the likelihood of developing an anxiety disorder.

Choice B reason: Lower educational attainment can be associated with increased stress and limited coping resources, but it is not the strongest risk factor compared to genetic and environmental influences.

Choice C reason: Family history of cancer and unemployment may contribute to stress, but they are not direct predictors of anxiety disorders.

Choice D reason: This client is at greatest risk because multiple adverse childhood experiences combined with parental history of anxiety disorders create both genetic and environmental

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A nurse is collecting data from a client who has schizophrenia and is taking fluphenazine. The nurse observes that the client’s tongue is protruding and he has irregular movements of his limbs. The nurse should identify that the client is exhibiting manifestations of which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a newly-admitted client who has obsessive-compulsive disorder. Which of the following interventions should the nurse plan to include?

Correct Answer is C

Explanation

A nurse is providing information to a client about risk factors for developing an anxiety-related disorder. Which of the following clients is at greatest risk for developing an anxiety-related disorder?

Correct Answer is D

Explanation

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