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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is D

Explanation

The correct answer is D.

Verify the medication three times with the medication administration record. The nurse should follow the six rights of medication administration: right client, right drug, right dose, right route, right time, and right documentation. To ensure the right drug and dose, the nurse should check the medication label against the medication administration record (MAR) three times: before removing the medication from the storage area, before preparing or measuring the medication, and before administering the medication to the client.

The nurse should also use two identifiers (such as name and date of birth) to verify the right client. The nurse should document medication administration after giving the medication, not before, to avoid errors and ensure accuracy. The nurse should administer time-critical medications within 30 minutes before or after the scheduled time, not 60 minutes.

A. Clean the wound from the center to the outer edges. B. Wear sterile gloves to remove the dressing. C. Remove the tape by pulling from the center of the dressing. D. Moisten the dressing before removal.

Correct Answer is A

Explanation

The correct answer is A. Clean the wound from the center to the outer edges.

Rationale: The nurse should clean the wound from the center to the outer edges to prevent contamination of the wound bed by bacteria or debris from the surrounding skin. The nurse should wear clean gloves, not sterile gloves, to remove the dressing, as wet-to-dry dressings are not sterile and do not require a sterile technique.

The nurse should remove the tape by pulling parallel to and away from the skin, not from the center of the dressing, to minimize skin damage and pain. The nurse should not moisten the dressing before removal, as this would defeat the purpose of wet-to-dry dressings, which are intended to debride necrotic tissue by adhering to it and pulling it off when dry.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering a client's morning oral medications. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is preparing to perform a wet-to-dry dressing change for a client who has an infected abdominal wound. Which of the following techniques should the nurse use when performing this dressing change?

Correct Answer is A

Explanation

A nurse is caring for a client who has end-stage kidney disease. The client has decided to stop dialysis treatment. Which of the following actions should the nurse take?

A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?

A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take?

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A nurse is assessing a client who is in skeletal traction for a fractured left tibia. The nurse should identify that which of the following findings indicates altered tissue perfusion of the affected extremity?

A nurse is reinforcing teaching with a client about intermittent catheterization to measure residual urine. Which of the following information should the nurse include in the teaching?

A nurse is suctioning the airway of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following findings should the nurse identify as an indication that the suctioning has been effective?