A nurse on a mental health unit observes a diagnosed schizophrenic patient on antipsychotics having an impaired gait and uncontrollable tremors. The nurse should recognize that which of the following adverse effects may be occurring?
Tardive dyskinesia.
Acute dystonia.
Pseudoparkinsonism.
Neuroleptic malignant syndrome.
The Correct Answer is C
The correct answer is choice C. Pseudoparkinsonism.
Choice A rationale:
Tardive dyskinesia is a long-term side effect of antipsychotic medications characterized by repetitive, involuntary movements, often around the mouth, such as lip-smacking, tongue protrusion, and chewing movements. It does not typically present with impaired gait and tremors.
Choice B rationale:
Acute dystonia involves sudden, severe muscle contractions, often affecting the neck, face, and back. Symptoms include twisting movements and abnormal postures, but it does not usually cause impaired gait and tremors.
Choice C rationale:
Pseudoparkinsonism is an adverse effect of antipsychotic medications that mimics the symptoms of Parkinson’s disease, including bradykinesia (slowness of movement), rigidity, tremors, and postural instability. The impaired gait and uncontrollable tremors observed by the nurse are characteristic signs of pseudoparkinsonism.
Choice D rationale:
Neuroleptic malignant syndrome is a rare but life-threatening reaction to antipsychotic medications. It presents with symptoms such as high fever, muscle rigidity, altered mental status, and autonomic dysfunction (e.g., unstable blood pressure, sweating). It does not typically present with impaired gait and tremors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A: "Assess the client's need for assistance with ADLS."
Choice A rationale:
Safety is the top priority when caring for a client with major depressive disorder. Assessing the client's ability to perform Activities of Daily Living (ADLS) helps determine her level of functioning and any potential risks. Ensuring that the client can meet her basic self-care needs is essential for her well-being.
Choice B rationale:
Encouraging the client to create her own schedule of daily activities can be a valuable intervention, but it should come after addressing safety concerns. Choice A takes precedence as it directly relates to the client's immediate well-being.
Choice C rationale:
Teaching the client to use passive communication is not appropriate. Passive communication may hinder the client's ability to express her needs and advocate for herself. Assertive communication skills are more beneficial for her overall mental health.
Choice D rationale:
Isolating the client from unit activities may exacerbate her feelings of depression and loneliness. Encouraging engagement with appropriate unit activities and social interactions can contribute to her sense of belonging and aid in her recovery.
Correct Answer is C
Explanation
Choice A rationale:
Ingesting lithium (Eskalith) on an empty stomach can lead to gastrointestinal upset. Therefore, clients are generally advised to take this medication with food or milk to minimize these side effects. This choice is incorrect.
Choice B rationale:
While sodium intake can impact lithium levels, clients are usually advised to maintain a consistent, moderate sodium intake rather than adopting a low-salt diet. Extreme dietary changes can affect lithium levels and potentially lead to toxicity, making this choice inaccurate.
Choice C rationale:
Monitoring blood levels of lithium is crucial to ensure therapeutic effectiveness and prevent toxicity. During the initiation phase, frequent monitoring, typically weekly, is necessary to establish the appropriate dosage for each individual. Lithium has a narrow therapeutic range, and blood levels need to be closely regulated.
Choice D rationale:
Discontinuing lithium abruptly can lead to worsened bipolar symptoms. Diarrhea can contribute to dehydration and electrolyte imbalances, potentially impacting lithium levels, but stopping the medication is not the initial action to take. Adjustments in dosage or management strategies are usually explored before considering discontinuation.
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