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 D
Explanation
A. In adults insert catheter approximately 16 cm (6.5 inches); in older children, 8– 12 cm (3–5 inches); in infants and young children, 4–7.5 cm (1.5–3 inches). Rule of thumb is to insert catheter distance from tip of nose (or mouth) to angle of mandible.
B. Suction should not be applied while inserting the catheter, as it could cause trauma to the mucosa and increase discomfort. Suction should only be applied while withdrawing the catheter, and it should be done intermittently to avoid injury and reduce the risk of hypoxia.
C. Suctioning should not exceed 10-15 seconds at a time to prevent hypoxia and other complications. Prolonged suctioning can lead to oxygen depletion and potential respiratory distress in the client.
D. Waiting at least 1 minute between suctioning attempts allows the client to recover and helps maintain adequate oxygenation. This pause is essential to prevent hypoxia and to ensure the client has time to breathe normally before the next suctioning attempt.
Correct Answer is B
Explanation
The correct answer is choice b. “I will stop what I am doing and lie down.”
Choice A rationale:
Taking two 325 milligram aspirin tablets at the same time is not the recommended immediate action for chest pain. Aspirin can help in preventing blood clots, but it is not the first step in managing acute angina.
Choice B rationale:
Stopping activity and lying down is the correct initial response to chest pain. This helps reduce the heart’s workload and can alleviate the pain.
Choice C rationale:
Calling the provider after taking one dose of nitroglycerin is important, but it is not the first step. The client should first stop activity and lie down, then take nitroglycerin if prescribed.
Choice D rationale:
Holding the breath and bearing down (Valsalva maneuver) is not appropriate for managing chest pain and can actually increase the heart’s workload, potentially worsening the situation.
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