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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Correct Answer is D

Explanation

The correct answer is D. Compare bilateral pedal pulses.

Rationale: The nurse should compare bilateral pedal pulses to assess for adequate circulation and perfusion to the lower extremities. Buck's traction is a type of skin traction that is widely used for broken femurs and hips, as well as fractures in the socket portion of the "ball-and-socket" hip joint (acetabular fractures). It uses splints, bandages, and adhesive tapes to position a limb near the fracture, then weights and pulleys are attached and pressure is applied. The nurse should not remove the weights for 20 min for the client's report of severe pain, as this would disrupt the alignment and traction of the fracture .

The nurse should not position the knot of the rope at the top of the pulley, as this would interfere with the smooth movement of the rope and reduce the effectiveness of traction. The nurse should not apply 6.8 kg (15 lb) of weight for use in traction, as this would exceed the recommended weight limit for skin traction and could cause skin damage or nerve injury. The weight should not exceed 4.5 kilograms at any point.

A. Monitor the client's range of motion every 60 min. B. Offer the client a nutritious snack every 4 hr. C. Plan to remove the restraints as soon as the client is calm D. Ensure that the provider has signed a prescription for restraints within 48 hr.

Correct Answer is C

Explanation

The correct answer is C. Plan to remove the restraints as soon as the client is calm. Physical restraints should be used as a last resort and for the shortest duration possible to ensure

client safety. The nurse should assess the client frequently and remove the restraints when they are no longer needed.

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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 caring for a client who has a femur fracture with the leg in Buck's traction. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse in an acute mental-health facility is caring for an adolescent who is exhibiting destructive behavior. Which of the following actions should the nurse take after applying physical restraints to the client?

Correct Answer is C

Explanation

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