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.)

Fine hand tremors and pill rolling

Urinary retention and constipation

Facial grimacing and eye blinking

Involuntary pelvic rocking and hip thrusting movements

Tongue thrusting and lip-smacking:

Answer and Explanation

Correct Answer : C,D,E

Fine hand tremors and pill rolling are not indicative of tardive dyskinesia. These symptoms are more commonly associated with other neurological or movement disorders.

B. Urinary retention and constipation:

Urinary retention and constipation are not symptoms of tardive dyskinesia. These symptoms are more related to anticholinergic effects of certain medications.

C. Facial grimacing and eye blinking:

Facial grimacing and repetitive, involuntary movements such as eye blinking are characteristic of tardive dyskinesia. These abnormal movements of the face and eyes are commonly seen in individuals who have been on long-term antipsychotic medications, especially older ones like haloperidol.

D. Involuntary pelvic rocking and hip thrusting movements:

TD often includes repetitive, purposeless movements of the limbs, trunk, and pelvis.

E. Tongue thrusting and lip-smacking:

Tongue thrusting and lip-smacking are classic symptoms of tardive dyskinesia. These repetitive, involuntary movements involving the mouth and tongue are often observed in individuals who have been on antipsychotic medications for an extended period of time.

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

Explanation

A. Nystagmus: Nystagmus is not a typical manifestation of alcohol withdrawal. It is more commonly associated with intoxication or neurological conditions. Therefore, it is not included in the effects of alcohol withdrawal.

B. Illusions: Illusions (misinterpretations of external stimuli) are common during alcohol withdrawal, especially in severe cases such as withdrawal delirium (delirium tremens). Clients may misinterpret shadows or objects as threatening.

C. Polyphagia: Polyphagia (excessive eating) is not a recognized manifestation of alcohol withdrawal. Clients with withdrawal may experience nausea or a lack of appetite rather than an increased appetite.

D. Tremors: Tremors, often called "the shakes," are one of the most common early signs of alcohol withdrawal. They usually begin within hours after alcohol cessation.

E. Seizures: Seizures, specifically generalized tonic-clonic seizures, are a serious complication of alcohol withdrawal. They can occur within 6–48 hours after the last drink and are part of alcohol withdrawal syndrome.

A. “I need to make sure that the potential victim is warned." B. "I need to keep the information confidential due to the client's right to privacy." C. “I can only discuss the client's threats with a court order." D. "I should verbally report this information to the psychiatrist."

Correct Answer is A

Explanation

A. "I need to make sure that the potential victim is warned."

Explanation: Correct Answer. When a client threatens to harm a specific individual, it's important to take steps to ensure the safety of both the client and the potential victim. Warning the potential victim or taking appropriate measures to protect them is an important action to take.

B. "I need to keep the information confidential due to the client's right to privacy."

Explanation: While respecting a client's right to privacy is important, when there's a threat of harm to an individual, it becomes a matter of safety that takes precedence over confidentiality.

C. "I can only discuss the client's threats with a court order."

Explanation: This statement is incorrect. When there's a credible threat to harm an individual, waiting for a court order is not an appropriate or timely response. Immediate actions should be taken to ensure safety.

D. "I should verbally report this information to the psychiatrist."

Explanation: While involving the psychiatrist is important for the client's overall care, it's essential to take more immediate steps to ensure the safety of the potential victim, such as notifying the appropriate authorities or taking appropriate precautions.

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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.)

Nursing Test Bank

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A nurse is teaching a newly-admitted client about the possible physical effects of alcohol withdrawal. Which of the following manifestation should the nurse include in the reaching? (Select all that apply.)

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

Explanation

A nurse is teaching a newly licensed nurse about appropriate actions to take when a client threatens to harm a specific individual. Which of the following statements by the newly licensed nurse indicates understanding?

Correct Answer is A

Explanation

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