After taking fluphenazine for several days, a client states to the nurse, "For some reason I can't sit still restless all the time." The nursing assessment of this client is likely to indicate which of the following?

Tardive dyskinesta

Pseudoparkinsonism

Akathisia

Acute dystonia

Answer and Explanation

The Correct Answer is C

A) Tardive dyskinesia: Tardive dyskinesia is a late-onset movement disorder that causes repetitive, involuntary movements, such as tongue protrusion or lip smacking. It typically develops after long-term use of antipsychotics like fluphenazine. Since the client reports restlessness shortly after starting the medication, this is unlikely to be tardive dyskinesia, which takes months to years to develop.

B) Pseudoparkinsonism: Pseudoparkinsonism is a side effect of antipsychotics that causes symptoms similar to Parkinson's disease, such as tremors, rigidity, and bradykinesia. While restlessness is not a hallmark symptom of pseudoparkinsonism, it could lead to a lack of coordination or stiffness, but it does not explain the client's feeling of being restless all the time.

C) Akathisia: Akathisia is a common side effect of antipsychotics, including fluphenazine. It is characterized by an intense feeling of restlessness and an inability to sit still, often accompanied by an urge to move. This matches the client's description of being restless and unable to sit still, making akathisia the most likely cause of their symptoms.

D) Acute dystonia: Acute dystonia involves painful, muscle spasms or abnormal postures, such as twisting of the neck or eyes rolling back, which can occur shortly after taking antipsychotics. However, this condition typically causes muscle rigidity or spasms rather than the restlessness that the client describes, making it less likely in this case.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","D","E"]

Explanation

A) Defensive responses to questions: During the preassaultive stage, a client may become increasingly defensive and may respond aggressively or defensively to questions, indicating rising tension and frustration. These defensive responses can signal the client’s growing agitation, which can escalate if not addressed appropriately.

B) Lethargy: Lethargy is not typical in the preassaultive stage of violence. Instead, clients in this stage are more likely to exhibit signs of agitation and heightened energy, not a decrease in activity or alertness. Lethargy might indicate a different issue, such as depression or sedation from medications.

C) Disorientation: Disorientation is not a hallmark of the preassaultive stage. While a client may experience confusion or irrational thinking during an acute episode of mental illness, disorientation is more commonly associated with conditions like delirium or cognitive disorders, rather than the early signs of violence.

D) Agitation: Agitation is a classic sign of the preassaultive stage. The client may show physical signs of distress, such as fidgeting, pacing, or increased restlessness. Agitation often precedes violent outbursts, and it’s an important sign that the nurse must be vigilant about in order to intervene before the situation escalates.
E) Facial grimacing: Facial grimacing can be a physical manifestation of increasing tension and aggression, indicating discomfort or frustration. This is another sign that the client may be entering the preassaultive stage, where heightened emotional responses are often accompanied by visible, nonverbal cues of agitation.

Correct Answer is ["1.3"]

Explanation

1. Convert the toddler's weight from pounds to kilograms:

1 lb = 0.454 kg

Weight in kg = 22 lb X 0.454 kg/lb = 9.988 kg (approximately 10 kg)

Calculate the total daily dose of furosemide:

Daily dose = 2 mg/kg X 10 kg = 20 mg

Calculate the dose per administration:

The daily dose is divided into equal doses every 8 hours. Since there are 24 hours in a day, this means 24 hours / 8 hours = 3 doses per day.

Dose per administration = 20 mg / 3 doses = 6.666... mg (approximately 6.67 mg)

Determine the concentration of the furosemide injection:

The available furosemide injection is 5 mg/mL.

Calculate the volume (in mL) to administer per dose:

Use the concentration as a conversion factor:

Volume (mL) = Dose per administration (mg) / Concentration (mg/mL) Volume (mL) = 6.67 mg / 5 mg/mL = 1.334 mL

Round to the nearest tenth:

1.3 mL.

View Question and Answer

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

After taking fluphenazine for several days, a client states to the nurse, "For some reason I can't sit still restless all the time." The nursing assessment of this client is likely to indicate which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client in an inpatient mental health unit. Which of the following findings should the nurse expect if the client I in the preassaultive stage of violence? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

A nurse is preparing to administer furosemide 2 mg/kg/day IV bolus divided in equal doses every 8hr to a toddler who weighs 22 lb . Available is furosemide injection 5 mg/mL. how many mL should the nurse administer per dose? (Round the answer to the nearest tenth.)

Correct Answer is ["1.3"]

Explanation

The nurse would recognize that a client understands the provided education regarding risperidone when the client states which of the following

A nurse is caring for a client who is taking clozapine. For which of the following findings should the nurse withhold the medication?

A nurse in an acute care mental health facility is caring for a client who has paranoid schizophrenia and suddenly becomes angry and uncontrollably violent toward staff. Which of the following medications should the nurse expect the provider to prescribe?

A nurse is caring for an adolescent client who begins to cry and states, "Nobody loves me. I don't deserve to be here!" Which of the following responses should the nurse make?

A patient states to the nurse, "I have no idea what typical antipsychotics but now I've been asked to take them." What symptoms should the nurse be prepared to discuss with the client?

A patient on the psychiatric unit took his first dose of chlorpromazine last night. The following morning, he approaches the nursing station complaining of severe spasms in his neck and back. The psych nurse informs the provider, and can expect an order for which medication?

A nurse is preparing to administer ceftriaxone 1 g IM every 12 hr. Available is ceftriaxone injection 450 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth.)

The admitting nurse asks a client, "Hi John, what would you like to talk about in group today? The client replies, "Hi john, what would you like to talk about in group today." The nurse should recognize this response as an example of which of the following?