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 D

Explanation

A. "Tell me who you think doesn't care about you."

Explanation: This response might come across as confrontational or defensive, which could discourage the client from opening up further. It's important to offer support and understanding rather than putting the client on the spot.

B. "Of course people care. Your family comes to visit every day."

Explanation: While it's true that the client's family visits, depression often distorts perception and emotions. Telling the client that people care might not be fully effective in addressing their feelings of worthlessness.

C. "Why do you feel that way?"

Explanation: This response opens the door for the client to express their emotions and thoughts. It encourages further conversation and helps the nurse understand the underlying causes of the client's feelings.

D. "I care about you, and I am concerned that you feel so sad."

Explanation: Correct Answer. This response shows empathy and genuine concern for the client's well-being. It acknowledges the client's emotions, offers support, and validates their feelings.

A. Determining if the client has psychotic thinking B. Asking the client to identify the cause of the crisis C. Identifying the client's coping skills D. identifying the client's support systems

Correct Answer is A

Explanation

The highest priority assessment in this situation is to determine if the client has psychotic thinking. Psychotic thinking can indicate a severe mental health condition that requires immediate attention and intervention. If the client is experiencing psychotic symptoms, they might be at risk of harming themselves or others. Identifying and addressing psychotic thinking is crucial to ensure the safety and well-being of the client and those around them.

B. Asking the client to identify the cause of the crisis.

While understanding the cause of the crisis is important for providing appropriate care, it is not the highest priority. Psychotic thinking or risk of harm takes precedence over understanding the cause.

C. Identifying the client's coping skills.

Coping skills are important for managing the crisis and promoting the client's well-being, but assessing for psychotic thinking and immediate safety concerns comes before evaluating coping skills.

D. Identifying the client's support systems.

Support systems are valuable for the client's overall recovery, but they are not as time-sensitive as assessing for psychotic thinking or imminent safety risks. Identifying support systems can come after addressing the immediate concerns.

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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

Naxlex Comprehensive Predictor Exams

A client becomes very dejected and states, "No one really cares what happens to me. Life isn't worth living anymore." Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority?

Correct Answer is A

Explanation

A client commits suicide in an acute mental health facility. Which of the following is the priority intervention for staff following this incident?

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