A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? Select all that apply.
Urinary retention and constipation.
Fine hand tremors and pill rolling.
Tongue thrusting and lip smacking.
Facial grimacing and eye blinking.
Involuntary pelvic rocking and hip thrusting movements.
Correct Answer : C,D,E
Choice A reason: Urinary retention and constipation are not typically associated with tardive dyskinesia, which is characterized by involuntary movements.
Choice B reason: Fine hand tremors and pill rolling are more commonly associated with Parkinson's disease rather than tardive dyskinesia.
Choice C reason: Tongue thrusting and lip smacking are classic signs of tardive dyskinesia, often resulting from long-term use of antipsychotic medications.
Choice D reason: Facial grimacing and eye blinking are also indicative of tardive dyskinesia, reflecting involuntary facial movements.
Choice E reason: Involuntary pelvic rocking and hip thrusting movements can be manifestations of tardive dyskinesia, representing involuntary movements of the body.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Acrophobia is the fear of heights, which is not indicated by the client's fear of being outdoors alone.
Choice B reason: Xenophobia is the fear of strangers or foreigners, which does not align with the client's described fear.
Choice C reason: Agoraphobia is the fear of open spaces or being in crowded, public places like markets. It also includes the fear of leaving a safe place, such as home, which aligns with the client's symptoms.
Choice D reason: Mysophobia is the fear of germs, which is not related to the fear of being outdoors alone.
Correct Answer is A
Explanation
Choice A reason: Given Brian's recent substance use and expression of not being able to tolerate depressive feelings, a suicide risk assessment is the highest priority to ensure his immediate safety.
Choice B reason: While a neurological assessment may be relevant, it is not the highest priority when there is a potential risk of suicide.
Choice C reason: Assessing the amount of current cannabis use is important but secondary to evaluating the risk of suicide.
Choice D reason: Marital status may inform social support but is not the highest priority in the context of potential self-harm.
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