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.

Answer and Explanation

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.

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Correct Answer is ["B","D"]

Explanation

Choice A reason: Having two nurses present at all times may not be necessary and could be overwhelming for the client, making them feel less in control.

Choice B reason: Continuous assessment of the client's anxiety level is important to ensure that the nurse can respond to the client's needs and maintain a sense of safety.

Choice C reason: While promoting independence is good, the client may need assistance, and providing it can be part of creating a safe environment.

Choice D reason: Asking for permission is crucial as it respects the client's autonomy and helps them feel in control of their body, which is essential for someone who has experienced abuse.

Choice E reason: Having security present outside the room may be excessive and could contribute to a feeling of being guarded or watched, which may not be conducive to feeling safe and secure.

A. Suicide risk assessment B. Neurological assessment C. Amount of current cannabis use D. Marital status

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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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.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has been a victim of abuse since childhood. Which actions by the nurse are important to ensure that the client feels safe, secure, and in control of their own body? Select all that apply.

Correct Answer is ["B","D"]

Explanation

Correct Answer is A

Explanation

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A nurse is discussing comorbidities associated with eating disorders with a newly admitted client. Which of the following conditions should the nurse include in the discussion? (Select all that apply)