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 A

Explanation

A. "Tell me what is concerning you."

This response is the most therapeutic option. It invites the spouse to share their concerns and feelings, showing empathy and active listening. It opens the door for effective communication and understanding the spouse's perspective.

B. "Your husband is making really good progress."

While this response provides information about the husband's progress, it doesn't directly address the spouse's concerns or feelings. The spouse's emotional state needs to be acknowledged and explored before discussing the husband's progress.

C. "Did your husband say something to upset you?"

This response makes an assumption that the husband said something to upset the spouse. It might come across as accusatory or dismissive of the spouse's feelings. It's important to give the spouse the opportunity to express their emotions in their own words.

D. "Crying helps us let things out and we feel better."

This response offers a general statement about crying, but it doesn't directly address the spouse's concerns or invite further conversation. While it's true that crying can be cathartic, the focus here should be on understanding the spouse's specific worries.

A. "Let's try to find ways to incorporate your partner's favorite food into her diet plan." B. "Why would you want to put your partner's health at further risk?" C. "Everyone likes food from home, but it can delay your partner's recovery." D. "You will need to discuss your concerns about your partner's diet with the provider."

Correct Answer is D

Explanation

A. "Let's try to find ways to incorporate your partner's favorite food into her diet plan."

While it's important to consider the client's preferences, dietary restrictions are often in place for specific health reasons. Trying to incorporate forbidden foods into the diet plan might compromise the client's health and recovery.

B. "Why would you want to put your partner's health at further risk?"

This response is confrontational and may not foster a productive conversation with the partner. It's important to address the situation professionally and collaboratively.

C. "Everyone likes food from home, but it can delay your partner's recovery."

While this response acknowledges the partner's feelings, it's essential to communicate more directly about involving the healthcare provider in decisions about the client's diet.

"D. You will need to discuss your concerns about your partner's diet with the provider."

Explanation: In matters involving a client's dietary plan and health, it's important to involve the healthcare provider to make informed decisions. The nurse should guide the partner to communicate their concerns with the provider who has the authority to evaluate the situation, consider the dietary restrictions, and make a decision that aligns with the client's health and recovery.

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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 nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband. Which of the following is a therapeutic nursing response?

Correct Answer is A

Explanation

A nurse is Laring for a client whose partner is requesting to bring the client food from home that is not allowed in the client's dietary plan. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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