A nurse is assessing a client who has schizophrenia which has been treated with fluphenazine for several years.

Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?.

Twisting tongue movements.

Shuffling gait.

Sudden onset of high fever.

Constant tapping of feet when sitting.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Twisting tongue movements are a common symptom of tardive dyskinesia (TD), a side effect of long-term use of antipsychotic medications like fluphenazine.

Choice B rationale:

Shuffling gait is more commonly associated with Parkinson’s disease and certain antipsychotic medications can cause Parkinson-like symptoms, but it is not a characteristic of TD2.

Choice C rationale:

Sudden onset of high fever is not associated with TD. It could be a sign of a serious condition like neuroleptic malignant syndrome, which requires immediate medical attention.

Choice D rationale:

Constant tapping of feet when sitting could be a sign of restlessness or akathisia, another potential side effect of antipsychotic medications, but it is not a specific sign of TD2.

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Correct Answer is A

Explanation

Choice A rationale:

Weight gain is a common side effect of risperidone. Antipsychotic medications like risperidone often lead to weight gain.

Choice B rationale:

Bradycardia is not typically associated with risperidone. Risperidone can cause mild heart rate changes, but significant bradycardia is not common.

Choice C rationale:

Nightmares are not a typical side effect of risperidone. Sleep disturbances can occur, but they are not the most common side effect.

Choice D rationale:

Dependent edema is not a common side effect of risperidone.

A. Assign a staff member to stay with the client at all times. B. Lock the doors to the unit and secure windows so they cannot be opened. C. Remove any objects from the client's environment that could be used for self-harm. D. Provide the client with plastic eating utensils for meals.

Correct Answer is A

Explanation

Choice A rationale:
Assigning a staff member to stay with the client at all times is the priority action when a client declines to make a safety contract. This is because the immediate safety of the client is the primary concern in such situations.
Choice B rationale:
Locking the doors to the unit and securing windows so they cannot be opened might be considered a safety measure, but it is not the priority. The focus should be on direct supervision to ensure safety.
Choice C rationale:
Removing any objects from the client’s environment that could be used for self-harm is important, but it is not the priority. The immediate safety of the client through constant supervision is the priority.
Choice D rationale:
Providing the client with plastic eating utensils for meals is a safety measure, but it is not the priority. The immediate safety of the client through constant supervision is the priority.

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A nurse is assessing a client who has schizophrenia which has been treated with fluphenazine for several years. Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has schizophrenia and is taking risperidone. Which of the following findings should the nurse expect?.

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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A nurse is assessing a client who has schizophrenia which has been treated with fluphenazine for several years.

Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?.