A nurse is caring for a client who has schizophrenia and is taking an antipsychotic medication. Which of the following screening tools should the nurse use to identify tardive dyskinesia?
Patient Health questionnaire 9
Mental Status Examination
Brief Psychiatric Rating Scale
Abnormal Involuntary Movement Scale
The Correct Answer is D
A. Incorrect. The Patient Health questionnaire is used to assess depression severity.
B. Incorrect. The Mental Status Examination assesses cognitive function and psychiatric symptoms.
C. Incorrect. The Brief Psychiatric Rating Scale assesses psychiatric symptoms but not specifically tardive dyskinesia.
D. Correct. The Abnormal Involuntary Movement Scale (AIMS. is specifically designed to screen for and assess the severity of tardive dyskinesia, which is a movement disorder associated with antipsychotic medications.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A.Restraints should be released more frequently, typically every 2 hours, to assess circulation, skin integrity, and range of motion, and to provide an opportunity for toileting and other needs.
B.It is essential to document the specific behaviors that led to the use of restraints, as this provides a clear rationale for why the restraints were necessary. This documentation is important for legal and clinical reasons and helps ensure that restraints are used appropriately and only when absolutely necessary.
C.Clients are not required to provide written consent for the use of restraints, especially in situations where restraints are necessary to protect the client or others from immediate harm. However, the nurse must follow the facility's protocol, which usually involves obtaining a physician's order and documenting the justification for the restraint use.
D.The nurse should check the client's status more frequently, typically every 15 minutes, to ensure the client's safety and well-being while in restraints.
Correct Answer is C
Explanation
Since the client is prescribed home oxygen at 1 to 2 L/min, a nasal cannula is the most appropriate device for oxygen delivery in this scenario. A nasal cannula consists of two small prongs that are inserted into the client's nostrils, delivering oxygen directly into the nasal passages. It is a comfortable and commonly used device for low-flow oxygen therapy.
Petroleum jelly is not directly related to oxygen therapy and is not typically required for the use of a nasal cannula.
A reservoir bag is not typically used with a nasal cannula. It is a component of a different oxygen delivery system called a non-rebreather mask, which is used for high-flow oxygen therapy or in emergency situations.
An oxygen mask is also not typically used with a nasal cannula. It is a separate oxygen delivery device that covers the client's mouth and nose, delivering oxygen at a higher flow rate. Masks may be used in situations where higher concentrations or flows of oxygen are required, or when the client is unable to tolerate or use a nasal cannula effectively.
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