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 A
Explanation
Choice A rationale:
Asking “What are the voices telling you to do?” shows empathy and concern without validating the hallucination.
Choice B rationale:
Asking “Why do you think you are hearing the voices?” might imply that the nurse is validating the hallucination.
Choice C rationale:
Telling the client “You need to understand that there are no voices.”. might make the client feel misunderstood.
Choice D rationale:
Telling the client “You need to tell the voices to leave you alone.”. is not recommended as it might validate the hallucination.
Correct Answer is D
Explanation
Choice A rationale:
Encouraging family to take the client out of the facility for short periods of time can be beneficial, but it does not address the sudden change in behavior.
Choice B rationale:
Rewarding the client for her change in behavior can reinforce positive behavior, but it does not address the sudden change in behavior.
Choice C rationale:
Asking the client why her behavior has changed can provide insight, but it does not ensure the safety of the client.
Choice D rationale:
Monitoring the client’s whereabouts at all times is important as a sudden change in mood can indicate a higher risk of suicide.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.