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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. For a client with a pre-pregnancy BMI of 30.5 (considered obese., an acceptable weight gain during pregnancy is typically around 1120 pounds (59 kg., making 16 pounds an appropriate option within this range.
B. Incorrect. A weight gain of 32 pounds would be considered excessive for a client with a pre-pregnancy BMI of 30.5.
C. Incorrect. A weight gain of 24 pounds might still fall within an acceptable range, but for a client with a pre-pregnancy BMI of 30.5, a weight gain of 16 pounds is a more appropriate option.
D. Incorrect. A weight gain of 8 pounds would likely be insufficient for a client with a pre-pregnancy BMI of 30.5.
Correct Answer is ["A","C","D","F","G","H"]
Explanation
A.The heart rate increased from 90/min on Day 1 to 110/min on Day 2, indicating tachycardia. This can signify an underlying issue, such as hypovolemia or sepsis, especially given the other concerning findings.
B.While the pain level increased from 3/10 to 6/10, pain itself is subjective and should be monitored closely. It may require adjustment in pain management but is not immediately life-threatening compared to other findings.
D.The client's confusion and slow response can indicate a change in neurological status, possibly related to electrolyte imbalances, dehydration, or infection. This is a significant finding that requires immediate attention.
C. The client's skin changed from warm and dry to pale, cool, and clammy, suggesting possible shock or hypoperfusion. This is a critical sign that needs to be communicated to the provider.
E.The respiratory rate increased from 18/min to 22/min, indicating mild respiratory distress. While concerning, it does not represent an acute emergency compared to other findings and should be monitored.
F.The blood pressure dropped from 126/78 mm Hg on Day 1 to 80/60 mm Hg on Day 2, indicating possible hypotension. This change could signify worsening clinical status, potentially indicating shock or significant fluid loss.
G.The urine output decreased significantly from 400 mL over 8 hours to 100 mL over 6 hours, indicating possible acute kidney injury or dehydration.
H.The client’s temperature has increased from 37.2°C (99°F) to 38.4°C (101.1°F), indicating a possible infection or inflammatory response.
I.The sodium level remains within normal limits (144 mEq/L) and does not show significant changes. Therefore, it does not require immediate reporting.
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