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","B","F"]
Explanation
A. Oxygen saturation level: The client is restless, not following commands, and has labored respirations with crackles and wheezes in the breath sounds. Monitoring the oxygen saturation level is essential to assess the client's respiratory status and oxygenation.
B. Tremors: The client has tremors in their hands. Considering the client's history of Parkinson's disease, changes in tremors should be monitored and addressed promptly.
C. The immediate concern is addressing the respiratory distress.
D. Heart rate may also be monitored, but it's not as critical in this context.
E. Chronic health conditions are relevant for the overall care plan, but they do not require immediate intervention as compared to respiratory and tremor issues.
F. Respiratory rate: The client has labored respirations and abnormal breath sounds (crackles and wheezes). Monitoring the respiratory rate is important to evaluate the client's breathing pattern and respiratory distress.
Correct Answer is A
Explanation
A. Correct. This instruction helps ensure proper identification of the newborn, reducing the risk of mix-ups.
B. Incorrect. While verifying credentials is important, this action might not be feasible for every nurse and situation.
C. Incorrect. Leaving the newborn unattended is not a safe practice.
D. Incorrect. Carrying the newborn to the nursery might expose the newborn to unnecessary risks and separation.
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