A nurse is assessing a client diagnosed with schizophrenia, which has been treated with fluphenazine (Prolixin) for several years. Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?
Twisting tongue movements.
Constant tapping of feet when sitting.
Shuffling gait.
Sudden onset of high fever.
The Correct Answer is A
Choice A rationale:
Twisting tongue movements are characteristic manifestations of tardive dyskinesia (TD). TD is a movement disorder associated with long-term use of antipsychotic medications like fluphenazine (Prolixin). These involuntary movements often involve the face and tongue and can be irreversible if not addressed promptly.
Choice B rationale:
Constant tapping of feet when sitting is not a typical manifestation of tardive dyskinesia. This type of movement might be related to restlessness or anxiety, but it is not specifically associated with the movement disorder caused by prolonged antipsychotic use.
Choice C rationale:
Shuffling gait can be associated with parkinsonism, which is another potential adverse effect of antipsychotic medications, including fluphenazine. However, for tardive dyskinesia, the characteristic movements are more often related to the face and mouth rather than the legs and gait.
Choice D rationale:
Sudden onset of high fever is not a manifestation of tardive dyskinesia. It could potentially be a sign of a different medical issue, such as an infection. However, it is not directly related to the movement disorder caused by long-term antipsychotic use.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A: "You may experience dizziness upon standing while taking this medication."
Choice A rationale:
This choice is the correct answer because haloperidol, an antipsychotic medication, can cause orthostatic hypotension, which leads to dizziness upon standing. Antipsychotic medications often affect blood pressure regulation and can result in a sudden drop in blood pressure when transitioning from sitting or lying down to standing. This explanation provides essential information to the client to help them understand potential side effects and take necessary precautions.
Choice B rationale:
This choice is incorrect. Haloperidol is not indicated for treating symptoms of obsessive-compulsive disorder (OCD). It is primarily used to manage symptoms of schizophrenia and other psychotic disorders. Providing false information about its indications is not appropriate and may lead to confusion.
Choice C rationale:
This choice is incorrect. Clients should never stop taking antipsychotic medications abruptly without consulting their healthcare provider. Discontinuing such medications can lead to withdrawal effects and a worsening of symptoms. Encouraging the client to stop the medication if side effects are bothersome is not appropriate and could potentially jeopardize their well-being.
Choice D rationale:
This choice is partially correct but not the best answer. While haloperidol can cause excessive salivation (sialorrhea) as a side effect, the primary concern in this situation should be related to orthostatic hypotension and dizziness upon standing. Mentioning excessive salivation would be helpful, but it's secondary to the risk of falls associated with orthostatic hypotension.
Correct Answer is C
Explanation
The correct answer is choice C. Suspended from school several times in the past year.
Choice A rationale:
The client's father's recent death (Choice A) is not a typical expected assessment finding of conduct disorder. While emotional disturbances can be associated with conduct disorder, the primary characteristics involve behavioral issues rather than reactions to significant life events.
Choice B rationale:
Adhering strictly to routines (Choice B) is not a common expected assessment finding of conduct disorder. Conduct disorder is characterized by patterns of defiant and disruptive behaviors, not necessarily a rigid adherence to routines.
Choice C rationale:
Suspended from school several times in the past year (Choice C) aligns with the expected assessment findings of conduct disorder. Conduct disorder often involves aggressive behavior towards others, violation of rules, and disregard for the rights of others, which can lead to disciplinary actions such as school suspensions.
Choice D rationale:
Experiencing frequent facial tics (Choice D) is not a typical expected assessment finding of conduct disorder. Facial tics are associated with conditions like Tourette's syndrome or other tic disorders, not conduct disorder.
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