A nurse is assessing a client diagnosed with schizophrenia who has been treated with fluphenazine (Prolixin) for several years. Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?
Sudden onset of high fever
Twisting tongue movements
Constant tapping of feet when sitting
Shuffling gait
The Correct Answer is B
Choice A reason:
A sudden onset of high fever is not a symptom of tardive dyskinesia (TD). High fever may indicate an infection or other serious conditions such as neuroleptic malignant syndrome, which is a different and more severe reaction to antipsychotic medications
Choice B reason:
Twisting tongue movements are a classic sign of tardive dyskinesia. TD is characterized by repetitive, involuntary, and purposeless movements that often affect the face, including the tongue. These movements result from long-term use of certain antipsychotic medications, like fluphenazine, which block dopamine receptors in the brain.
Choice C reason:
Constant tapping of the feet when sitting could be a sign of restlessness or akathisia, which is another side effect of antipsychotic medications but is not specifically indicative of tardive dyskinesia. TD typically involves more complex movements of the limbs, not just simple tapping.
Choice D reason:
A shuffling gait is more commonly associated with parkinsonism or pseudoparkinsonism, which can also be a side effect of antipsychotic medications. It is not a typical manifestation of tardive dyskinesia, which usually presents with involuntary movements of the face, tongue, and upper body
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Asking "How long has this been going on?" is a relevant question that can help the nurse understand the duration of the client's anxiety and concentration issues. However, it may not immediately provide the empathetic connection that can encourage the client to open up more about their feelings.
Choice B Reason:
"It sounds like you're having a difficult time" is an empathetic statement that acknowledges the client's distress and can help establish rapport. This response validates the client's feelings and invites them to share more about their experience, which is essential in forming a therapeutic nurse-client relationship.
Choice C Reason:
"Why do you think you are so anxious?" could prompt the client to reflect on possible causes of their anxiety, but it might also be perceived as confrontational or accusatory. It's important for the nurse to create a nonjudgmental atmosphere that encourages open communication.
Choice D Reason:
"Have you talked to your parents about this yet?" assumes that the client's parents are part of their support system and that the client is willing or able to discuss their anxiety with them. This question might not be appropriate for all clients, especially if family relationships are a source of stress.
Correct Answer is C
Explanation
Choice A reason:
This statement reflects anger and distrust towards the physician rather than denial. It indicates a belief that the doctor's incompetence is the reason for the poor prognosis, which is a common reaction in the anger stage of grief.
Choice B reason:
This response suggests a lack of energy, which could be associated with depression, another stage of grief. It does not indicate denial, as the client is not refusing the reality of the diagnosis but expressing feelings of lethargy and possible sadness.
Choice C reason:
This statement is a classic example of denial, one of the first stages of grief identified by Elisabeth Kübler-Ross. The client is refusing to accept the reality of the prognosis, which is a defense mechanism to protect oneself from the initial shock and pain of a distressing diagnosis.
Choice D reason:
This response indicates acceptance, the final stage of grief, where the individual acknowledges the reality of the situation and is at peace with the impending outcome.
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