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?
Mental Status Examination
Brief Psychiatric Rating Scale
Patient Health Questionnaire-9
Abnormal Involuntary Movement Scale
The Correct Answer is D
Answer: D. Abnormal Involuntary Movement Scale
Rationale: The Abnormal Involuntary Movement Scale is a diagnostic tool that assesses the severity of tardive dyskinesia, a disorder that results in involuntary repetitive body movements caused by long-term use of antipsychotic drugs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D.
Chadwick's sign. Chadwick's sign is a bluish discoloration of the cervix, vagina, and vulva caused by increased blood flow to these areas during pregnancy. It usually appears around 6 to 8 weeks of gestation and persists until delivery. It is one of the presumptive signs of pregnancy, which are subjective changes that suggest pregnancy but are not conclusive. Ballottement is a technique of palpating the uterus to detect fetal movement when a finger is inserted into the vagina and tapped against the cervix. It can be performed between 16 and 28 weeks of gestation and is also a presumptive sign of pregnancy.
Chloasma is a condition characterized by brown patches on the face that may occur during pregnancy due to hormonal changes. It is also known as melasma or mask of pregnancy and usually fades after delivery. Hegar's sign is a softening of the lower uterine segment that can be felt during bimanual examination around 6 weeks of gestation. It is one of the probable signs of pregnancy, which are objective changes that strongly indicate pregnancy but are not diagnostic.
Correct Answer is C
Explanation
The correct answer is C. The nurse should document factual and objective information about the incident, such as what the client said and what actions were taken by the nurse and other staff members. The nurse should not document opinions or assumptions about the cause of the fall, such as blaming the assistive personnel or stating that the client has no injuries without performing a thorough assessment. The nurse should also not document that an incident report was completed and sent to risk management, as this is confidential information that should not be part of the medical record.
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