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:
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Tell me about the concerns that you have regarding your relationship."
This choice is an appropriate and open-ended question that encourages the client to express their feelings and concerns. It helps in building rapport and understanding the client's perspective.
B. "Relationship difficulties are stressful and require effort to resolve."
This choice acknowledges the challenges of relationship difficulties and conveys a supportive and empathetic attitude. It is a reasonable and non-biased statement.
C. "We could develop a plan for how to talk about this with your partner."
This choice suggests a proactive approach to address the client's concerns and promote effective communication. It is a helpful and appropriate statement.
D. "You should try to see your partner's point of view before your own."
This statement implies a biased approach, suggesting that the client should prioritize their partner's perspective over their own. While empathy and understanding are important in relationships, it's not appropriate for a healthcare professional to imply that one perspective is more important than the other. The nurse should encourage open communication and understanding from both sides rather than favoring one viewpoint.
Correct Answer is ["24"]
Explanation
To calculate the mL/hr for the heparin infusion, you can use the formula:
mL/hr = (Total units required per hour) / (Units/mL in the solution)
Given:
Total units required per hour = 1,200 U/hr
Units/mL in the solution = 25,000 U / 500 mL = 50 U/mL
Plugging in the values:
mL/hr = (1,200 U/hr) / (50 U/mL)
mL/hr = 24 mL/hr (rounded to the nearest tenth)
Therefore, the nurse should set the IV pump to deliver 24 mL/hr for the heparin infusion.
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