A nurse performs an Abnormal Involuntary Movement Scale (AIMS) assessment on a client who began taking loxapine 2 years ago for the treatment of schizophrenia. Findings include lip smacking, tongue protrusion, and facial grimacing. The nurse should suspect which of the following?
Parkinsonism
Tardive dyskinesia
Anticholinergic effects
Akathisia
The Correct Answer is B
Tardive dyskinesia (TD) is a late-onset, potentially irreversible movement disorder associated with long-term use of first-generation antipsychotics like loxapine. It is characterized by involuntary, repetitive movements, particularly of the face, lips, tongue, and sometimes the extremities. Regular monitoring using the Abnormal Involuntary Movement Scale (AIMS) is crucial for early detection and intervention.
Rationale for correct answer:
B. Tardive dyskinesia – Correct. TD often develops after months to years of antipsychotic therapy. The hallmark signs include lip smacking, tongue protrusion, chewing motions, and facial grimacing, matching the client’s AIMS findings. Early detection is important, as symptoms may become irreversible if the drug is continued.
Rationale for incorrect answer:
A. Parkinsonism – Typically presents with rigidity, bradykinesia, and tremors, resembling Parkinson’s disease. These symptoms usually appear early in treatment, not after long-term use.
C. Anticholinergic effects – These include dry mouth, blurred vision, constipation, and urinary retention. They do not explain the involuntary facial and tongue movements observed in this client.
D. Akathisia – Characterized by inner restlessness, inability to sit still, and pacing, typically occurring shortly after starting or increasing antipsychotic therapy. The client’s symptoms are distinctly involuntary movements, not restlessness.
Take-home points:
- Tardive dyskinesia is a late-onset, often irreversible adverse effect of long-term antipsychotic therapy.
- Regular AIMS assessments are essential for early detection and intervention.
- Prompt reporting of symptoms can guide the provider in adjusting therapy to prevent progression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Antipsychotic medications, particularly first-generation (typical) and many second-generation (atypical) agents, are primarily used to manage psychotic symptoms such as hallucinations, delusions, and disorganized thinking. Their main mechanism involves modulating neurotransmitter activity in the brain, especially by affecting dopamine pathways, which play a key role in regulating mood, cognition, and perception.
Rationale for correct answer:
A. Blocking actions of dopamine – Antipsychotics exert their therapeutic effect by blocking dopamine D2 receptors in the mesolimbic pathway, which reduces positive symptoms of psychosis such as hallucinations and delusions. Some atypical antipsychotics also target serotonin receptors, improving negative symptoms.
Rationale for incorrect answer:
B. Blocking actions of epinephrine – Epinephrine is involved in the fight-or-flight response and does not play a central role in psychotic symptom development. Blocking epinephrine would not relieve hallucinations or delusions.
C. Promoting prostaglandin synthesis – Prostaglandins are mediators of inflammation and pain, unrelated to the mechanism of antipsychotic drugs.
D. Enhancing the action of gamma-aminobutyric acid (GABA) – GABA enhancement is the mechanism of benzodiazepines and some sedative-hypnotics, not antipsychotics. It primarily produces CNS depression rather than antipsychotic effects.
Correct Answer is B
Explanation
Many antipsychotic medications, such as fluphenazine, have anticholinergic side effects due to their blockade of muscarinic receptors. These effects—dry mouth, blurred vision, constipation, and urinary retention—can significantly impact comfort and adherence. Nurses play a key role in teaching clients self-care strategies to reduce these symptoms and maintain compliance with therapy.
Rationale for correct answer:
B. Chew sugarless gum to moisten the mouth – Dry mouth is a common anticholinergic effect of fluphenazine. Chewing sugarless gum stimulates salivary flow, helping to moisten the oral mucosa and prevent dental problems. This is an effective, nonpharmacologic coping strategy.
Rationale for incorrect answer:
A. Take the medication in the morning to prevent insomnia – Fluphenazine is more likely to cause sedation than insomnia. Adjusting the time of administration does not address anticholinergic effects such as dry mouth.
C. Use cooling measures to decrease fever – While anticholinergic drugs can reduce sweating and theoretically contribute to heat intolerance, fever is not the most common issue. Cooling measures are not a primary intervention for typical anticholinergic effects in this context.
D. Take an antacid to relieve nausea – Antacids are not indicated for anticholinergic effects. In addition, they can interfere with the absorption of some oral medications, including certain antipsychotics.
Take-home points:
- Anticholinergic effects of fluphenazine include dry mouth, constipation, urinary retention, and blurred vision.
- Nonpharmacologic interventions, such as chewing sugarless gum or sipping water, can improve comfort and adherence.
- Client education should focus on practical, daily strategies to manage side effects without introducing unnecessary medications.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.