The nurse is administering medications to the client and is monitoring potential adverse effects of medications.

For each body system below, click to specify the assessment findings that could indicate a serious adverse reaction. Each body system may support more than 1 potential assessment finding. To deselect a finding click on the finding again.

Body system	Findings
Head. Eyes. Ears. Nose, and Throat (HEENT)	Yellowing of the eyes Blurred vision Dry eyes
Gastrointestinal	Abdominal pain Weight gain
Hematologic	Increased bruising Increased bleeding tendancies Insomnia
Genitourinary	Darkening of the urine Urinary frequency

A) Place the bedside table 2 feet away from the bed: This is not recommended for a client at risk for falls. The bedside table should be within reach of the client to avoid the need for excessive movement, which could increase the risk of a fall, especially if the client is unsteady or disoriented. Ideally, the bedside table should be placed within arm’s reach for convenience and safety.

B) Keep lighting in the home dim: Dim lighting increases the risk of falls by making it harder for the client to see obstacles and navigate safely. It is important to ensure that lighting is bright enough to illuminate walking areas, hallways, and other areas that might present a fall risk.

C) Place area rugs on slick floor surfaces: Area rugs on slick surfaces are hazardous as they can cause tripping or slipping, increasing the risk of a fall. It is best to remove rugs or ensure they are securely fastened to prevent them from sliding. Non-slip rugs or floor mats can be used, but they should not be placed on slick surfaces.

D) Move the client's bed to the main floor of the house: Moving the client's bed to the main floor is a good safety measure, especially if the client has difficulty navigating stairs. This reduces the need for the client to climb stairs, which can be dangerous and increase the risk of falls. Having the bed on the main floor ensures that the client can easily access their sleeping area without the risk of falling on stairs.

A) Patient Health Questionnaire - 9:
The Patient Health Questionnaire-9 (PHQ-9) is a screening tool used to assess the severity of depression in a client. It is not specific to detecting tardive dyskinesia, which is a movement disorder caused by long-term use of antipsychotic medications. Therefore, this tool is not appropriate for assessing tardive dyskinesia.

B) Abnormal Involuntary Movement Scale:
The Abnormal Involuntary Movement Scale (AIMS) is the correct tool to screen for tardive dyskinesia. It is specifically designed to assess involuntary movements, such as those seen in tardive dyskinesia, which is a common side effect of long-term use of antipsychotic medications. The AIMS evaluates the presence and severity of abnormal movements, making it the most appropriate tool for this purpose.

C) Mental Status Examination:
The Mental Status Examination (MSE) is a broad assessment used to evaluate a client’s cognitive and emotional functioning. It includes aspects such as appearance, behavior, mood, thoughts, and perception but does not specifically assess for movement disorders like tardive dyskinesia. While it can provide useful information about a client's mental state, it is not focused on detecting motor side effects of antipsychotic medications.

D) Brief Psychiatric Rating Scale:
The Brief Psychiatric Rating Scale (BPRS) is used to assess the severity of psychiatric symptoms, including delusions, hallucinations, and mood disturbances, primarily in individuals with schizophrenia or other psychiatric disorders. It does not specifically assess for tardive dyskinesia, so it is not the most appropriate screening tool for identifying this condition.