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","B","E"]
Explanation
Answer and explanation
The correct answers are choices A. Depression, B. Obsessive-compulsive disorder, E. Anxiety.
Choice A rationale:
Depression commonly coexists with eating disorders. The individual's distorted body image, feelings of low self-worth, and dietary restrictions can contribute to the development of depressive symptoms.
Choice B rationale:
Obsessive-compulsive disorder (OCD) often occurs alongside eating disorders. The obsessions and compulsions seen in OCD can overlap with behaviors related to food, eating rituals, and body image, reinforcing the eating disorder pathology.
Choice C rationale:
Schizophrenia is not typically considered a comorbidity of eating disorders. Schizophrenia involves disruptions in thought processes, emotions, and perceptions, which are distinct from the cognitive distortions and behaviors associated with eating disorders.
Choice D rationale:
Breathing-related sleep disorder is not a commonly recognized comorbidity of eating disorders. While sleep disturbances might occur in individuals with eating disorders due to physical discomfort or anxiety, a specific link to breathing-related sleep disorder is less established.
Choice E rationale:
Anxiety is a well-recognized comorbidity of eating disorders. Anxiety often accompanies the intense fears, worries, and preoccupations related to body weight, shape, and eating behaviors that are characteristic of eating disorders.
Correct Answer is A
Explanation
The correct answer is choice A: "Assess the client's need for assistance with ADLS."
Choice A rationale:
Safety is the top priority when caring for a client with major depressive disorder. Assessing the client's ability to perform Activities of Daily Living (ADLS) helps determine her level of functioning and any potential risks. Ensuring that the client can meet her basic self-care needs is essential for her well-being.
Choice B rationale:
Encouraging the client to create her own schedule of daily activities can be a valuable intervention, but it should come after addressing safety concerns. Choice A takes precedence as it directly relates to the client's immediate well-being.
Choice C rationale:
Teaching the client to use passive communication is not appropriate. Passive communication may hinder the client's ability to express her needs and advocate for herself. Assertive communication skills are more beneficial for her overall mental health.
Choice D rationale:
Isolating the client from unit activities may exacerbate her feelings of depression and loneliness. Encouraging engagement with appropriate unit activities and social interactions can contribute to her sense of belonging and aid in her recovery.
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