The nurse is caring for a patient who is being treated with antipsychotic medications. As part of the plan of care, the nurse monitors the patient for dyskinesia. What would the nurse assess with dyskinesia?

Involuntary movements of the mouth and tongue

Abnormal breathing

Migraine headache, hypertension

Severe flushing, headache, and tremors

Answer and Explanation

The Correct Answer is A

A. Involuntary movements of the mouth and tongue: Dyskinesia, particularly tardive dyskinesia, involves involuntary movements, often of the mouth, tongue, and sometimes other parts of the body.
B. Abnormal breathing: This is not a typical manifestation of dyskinesia.
C. Migraine headache, hypertension: These symptoms are not associated with dyskinesia.
D. Severe flushing, headache, and tremors: These symptoms do not describe dyskinesia, although tremors can be seen in other movement disorders.

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Correct Answer is C

Explanation

A. A resident with dementia who requires assistance eating: While this resident might have complications due to a weakened immune system, chemotherapy significantly increases the risk of complications from herpes zoster.

B. A resident who is sexually active: Sexual activity does not increase the risk of complications from herpes zoster.

C. A resident who is undergoing chemotherapy for breast cancer: Chemotherapy significantly compromises the immune system, making the resident more susceptible to severe complications from herpes zoster.

D. A resident recovering from a hip fracture: While recovering from a hip fracture is a stressor, it does not have as significant an impact on the immune system as chemotherapy.

A. Each evening B. Once every shift C. Every 4 hours D. Every 2 hours

Correct Answer is D

Explanation

A. Each evening: Turning the patient only once per day is insufficient to prevent pressure injuries.
B. Once every shift: This is also inadequate as it does not provide the frequent repositioning necessary to prevent pressure injuries.
C. Every 4 hours: While better than every shift, every 4 hours may still not be frequent enough to prevent pressure injuries in at-risk patients.
D. Every 2 hours: Frequent repositioning, such as every 2 hours, is essential for pressure injury prevention in bedfast patients.

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The nurse is caring for a patient who is being treated with antipsychotic medications. As part of the plan of care, the nurse monitors the patient for dyskinesia. What would the nurse assess with dyskinesia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Several residents in a long term care facility have been diagnosed with herpes zoster. Which resident will require the closest observation for development of complications?

Correct Answer is C

Explanation

Because thin skin and lack of subcutaneous fat predisposes the older adult to pressure injuries, the nurse alters the care plan to include turning the bedfast patient how often?

Correct Answer is D

Explanation

A nurse is caring for a patient who has anxiety attacks. What symptoms would indicate that the patient is experiencing a severe anxiety attack?

Which is important for the nurse to assess when inspecting the skin of a patient?

Which areas are affected only minimally by age?

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