An 11-year-old client has been hospitalized on the adolescent psychiatry unit with severe depression. For the past several weeks, the client has been prescribed a selective serotonin reuptake inhibitor (SSRI). What is the priority nursing action?

Monitor food intake and eliminate potential sources of tyramine.

Assess for weight loss and difficulty sleeping.

Monitor the client for migraines.

Implement suicide precautions.

Answer and Explanation

The Correct Answer is D

D. Children and adolescents with depression, especially when initiating or adjusting antidepressant medications like SSRIs, are at an increased risk of suicidal ideation and behavior. Therefore, it is crucial to prioritize the safety of the client by implementing suicide precautions, which may include close observation, removing potential means of self-harm, and involving the client in structured activities under supervision.

A. Monitoring food intake and eliminating potential sources of tyramine are considerations for clients taking monoamine oxidase inhibitors (MAOIs), another class of antidepressant medications, due to the risk of hypertensive crisis.

B. Weight loss and difficulty sleeping are potential side effects of SSRIs that may occur, particularly during the initial phases of treatment. However, suicide precautions are a priority

C. While SSRIs may cause headaches or migraines as potential side effects, monitoring for migraines specifically would not typically be a priority

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Correct Answer is ["A","B","C"]

Explanation

A. Tardive dyskinesia can involve abnormal, involuntary movements of the hips, pelvis, and trunk.
B. Facial grimacing and eye blinking are common manifestations of tardive dyskinesia. These movements involve involuntary contractions of facial muscles, leading to facial distortions and repetitive blinking.
C. Tongue thrusting and lip smacking are classic signs of tardive dyskinesia. These movements involve involuntary protrusion of the tongue and repetitive puckering or smacking of the lips.

D. Fine hand tremors and pill rolling movements are more commonly associated with other movement disorders, such as Parkinsonism, which can also be caused by certain antipsychotic medications but are distinct from tardive dyskinesia.
E. Urinary retention and constipation are not typical symptoms of tardive dyskinesia. These symptoms may occur due to other factors, such as anticholinergic effects of medications or medical conditions unrelated to tardive dyskinesia.

A. Neuroleptic Malignant Syndrome B. Dysthymia C. Tardive dyskinesia D. Akathisia

Correct Answer is C

Explanation

C. Tardive dyskinesia is a movement disorder characterized by repetitive, involuntary movements of the face, tongue, and sometimes other parts of the body. These movements can include lip smacking, tongue protrusion, grimacing, and rapid eye blinking. Tardive dyskinesia is a well-known adverse effect associated with long-term use of antipsychotic medications, particularly first- generation antipsychotics such as chlorpromazine.
A. Neuroleptic Malignant Syndrome is a rare but serious adverse reaction to antipsychotic medications, characterized by symptoms such as severe muscle rigidity, high fever, altered mental status (e.g., confusion), autonomic instability (e.g., fluctuations in blood pressure, heart rate), and elevated creatine phosphokinase (CPK) levels.
B. Dysthymia is a chronic mood disorder characterized by persistent feelings of sadness, hopelessness, and low self-esteem. Dysthymia is not directly related to the involuntary movements described in the scenario and is unlikely to be the cause of the client's symptoms.
D. Akathisia is a movement disorder characterized by inner restlessness and the inability to sit still. Akathisia is a common side effect of antipsychotic medications and can be distressing for affected individuals. However, the symptoms described in the scenario, specifically involuntary movements of the tongue and face, are more indicative of tardive dyskinesia rather than akathisia.

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An 11-year-old client has been hospitalized on the adolescent psychiatry unit with severe depression. For the past several weeks, the client has been prescribed a selective serotonin reuptake inhibitor (SSRI). What is the priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? (Select all that apply)

Correct Answer is ["A","B","C"]

Explanation

A nurse is assessing a client who has schizophrenia and has been on long-term treatment with chlorpromazine. He notes the client is experiencing some involuntary movements of the tongue and face. The nurse should suspect the client has developed which of the following adverse effects?

Correct Answer is C

Explanation

A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting. and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take?

A nurse is caring for a client who has depression. The client refuses to get out of bed, go to activities, or participate in any of the unit's programs. Which of the following responses should the nurse make?

A nurse is caring for a client who has schizophrenia and generalized anxiety disorder. The client has a prescription for alprazolam 0.25 mg PO every 8 hr PRN anxiety. For which of the following client statements should the nurse consider administering alprazolam?

A nurse is caring for an adolescent who is experiencing indications of depression. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is caring for a client who has major depressive disorder and was prescribed fluoxetine 2 weeks ago. The client reports having an improved appetite, but still feels very depressed and is still having trouble sleeping. Which of the following actions should the nurse take?

A nurse is caring for a client with delirium who is experiencing illusions. What environmental conditions should the nurse arrange for this client?

A nurse is caring for a client who has major depressive disorder and attempted suicide. The client tells the nurse. "I should have died because I am totally worthless." Which of the following responses should the nurse make?

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