A patient taking a first generation anti-psychotic medication is noted to grimace and smack both lips. The patient's neck and shoulders twisting in a snakelike motion. What problem would the nurse suspect?

Tardive dyskinesia

Agranulocytosis

Akathisia

Dystonic reaction

Answer and Explanation

The Correct Answer is A

A. Tardive dyskinesia: This involves repetitive, involuntary movements such as lip smacking, grimacing, and abnormal tongue or neck motions. These symptoms are characteristic of tardive dyskinesia, a long-term side effect of first-generation antipsychotics caused by dopamine receptor hypersensitivity.

B. Agranulocytosis: This is a serious adverse effect but is not associated with abnormal motor movements. Instead, it presents with signs of infection such as fever, sore throat, and decreased white blood cell count, making it unrelated to the client’s current symptoms.

C. Akathisia: This condition is marked by restlessness, pacing, and an inability to remain still. It does not involve lip smacking, grimacing, or twisting movements, so the client’s presentation does not align with akathisia.

D. Dystonic reaction: Acute dystonia involves sudden, painful muscle contractions such as eye deviation, neck spasms, or jaw locking. The patient’s slow, repetitive, snakelike twisting movements and lip smacking are more consistent with tardive dyskinesia.

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Correct Answer is B

Explanation

A. Scattered rhonchi and crackles with an elevated WBC count: These findings suggest an acute respiratory infection or pneumonia, not chronic hypoxemia. Elevated WBC count points to infection rather than a long-term adaptation to COPD.

B. Clubbing of the fingers and polycythemia: These are expected in chronic hypoxemia. Clubbing results from prolonged low oxygen levels, while polycythemia develops as the body compensates by producing more red blood cells to increase oxygen-carrying capacity.

C. Copious amounts of rust-colored sputum with cyanosis: Rust-colored sputum is typically associated with bacterial pneumonia, particularly pneumococcal infection, not chronic hypoxemia. Cyanosis may occur, but the sputum description makes this finding less appropriate.

D. Distended neck veins and dependent edema: These findings are consistent with cor pulmonale or right-sided heart failure, a complication of COPD, but they are not the expected baseline findings of chronic hypoxemia itself.

A. Schedule a chest x-ray to evaluate for active pulmonary tuberculosis B. Instruct the client to begin a full course of antitubercular medications immediately C. Repeat the Mantoux test in 3 months to confirm the result D. Document the result as negative since the client has no symptoms

Correct Answer is A

Explanation

A. Schedule a chest x-ray to evaluate for active pulmonary tuberculosis: A positive Mantoux test with induration ≥10 mm in a client without prior TB exposure indicates possible latent TB infection. A chest x-ray is necessary to rule out active disease before initiating treatment and to guide further management.

B. Instruct the client to begin a full course of antitubercular medications immediately: Starting treatment without confirming whether the infection is latent or active could be inappropriate and may lead to unnecessary drug exposure and side effects. Confirmation through imaging and possibly further testing is required first.

C. Repeat the Mantoux test in 3 months to confirm the result: Repeating the test is not necessary because an induration of 12 mm already meets the criteria for a positive result in most adults. Delaying further evaluation could postpone appropriate diagnosis and management.

D. Document the result as negative since the client has no symptoms: Absence of symptoms does not rule out latent tuberculosis. Documenting the result as negative would be inaccurate and could delay treatment or preventive measures, increasing the risk of future disease activation.

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A patient taking a first generation anti-psychotic medication is noted to grimace and smack both lips. The patient's neck and shoulders twisting in a snakelike motion. What problem would the nurse suspect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following assessment findings would be expected in a client with chronic hypoxemia due to chronic obstructive pulmonary disease (COPD)?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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