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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Borderline: Borderline personality disorder is associated with unstable mood, intense fear of abandonment, impulsivity, and self-destructive behaviors. While these clients may struggle with relationships, they do not exhibit grandiosity or an excessive need for admiration.
B. Schizoid: Schizoid personality disorder involves emotional detachment, preference for solitary activities, and limited expression of emotions. Clients with this disorder avoid social interactions but do not display traits of grandiosity or admiration-seeking.
C. Narcissistic: Narcissistic personality disorder is characterized by an inflated sense of self-importance, constant need for admiration, and lack of empathy toward others. These clients often exploit relationships for personal gain and require recognition to maintain self-esteem.
D. Histrionic: Histrionic personality disorder is marked by excessive emotionality, attention-seeking behavior, and dramatic expression. While they crave approval, they do not exhibit the pervasive grandiosity and lack of empathy that define narcissistic personality disorder.
Correct Answer is D
Explanation
A. Pancreatic enzymes: These values are primarily monitored in conditions affecting the pancreas, such as pancreatitis or pancreatic cancer. They are not the priority lab values to monitor in a client receiving chemotherapy.
B. Helicobacter pylori results: H. pylori testing is important for gastrointestinal disorders such as peptic ulcers or gastric cancer risk, but it is not a relevant or routine diagnostic value to monitor during chemotherapy treatment.
C. Kidney function values: Kidney function is important when chemotherapy agents are nephrotoxic, but monitoring kidney function is not as consistently crucial as monitoring bone marrow suppression, which occurs universally with many chemotherapy agents.
D. Cells produced in the bone marrow: Chemotherapy suppresses bone marrow activity, leading to decreased production of white blood cells, red blood cells, and platelets. Monitoring these values is essential to detect infection risk, anemia, or bleeding tendencies.
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