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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Monitoring the client closely to prevent self-mutilation is more associated with self-harm disorders rather than dependent personality disorder.
Choice B rationale:
Giving positive feedback when the client is assertive with staff or clients can encourage independence and confidence.
Choice C rationale:
Discouraging flamboyant or seductive behaviors is more related to histrionic personality disorder.
Choice D rationale:
Setting limits to prevent exploitation of other clients is more associated with antisocial personality disorder.
Correct Answer is C
Explanation
Choice A rationale:
A lithium level of 1.8 mEq/L is above the therapeutic level for initial treatment (0.8 to 1.4 mEq/L)3.
Choice B rationale:
A lithium level of 1.8 mEq/L is above, not below, the therapeutic treatment level.
Choice C rationale:
A lithium level of 1.8 mEq/L is at the toxic level. A blood lithium level greater than 1.5 mEq/L indicates toxicity.
Choice D rationale:
A lithium level of 1.8 mEq/L is not within the maintenance treatment level (0.4 to 1.3 mEq/L)3.
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