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 C
Explanation
Encouraging client feedback about their satisfaction with the facility experience is related to communication and patient-centered care, but it's not directly addressing the client's autonomy in making decisions about their own care or treatment.
B) Explaining unit rules and policies regarding unacceptable behaviors:
Explaining unit rules and policies is important for maintaining a safe and therapeutic environment, but it's more about providing information and setting expectations rather than addressing the client's autonomy.
C) Supporting the client's wish to refuse prescribed medications.
Explanation:
Autonomy is the ethical principle that emphasizes an individual's right to make decisions about their own care and treatment. In the context of healthcare, respecting autonomy means that healthcare professionals should honor a patient's decisions as long as they are informed and capable of making those decisions. By supporting the client's wish to refuse prescribed medications, the nurse is respecting the client's autonomy and allowing them to have control over their own treatment decisions.
D) Making sure the client understands expectations for client participation:
Ensuring that the client understands expectations for participation is important for collaboration in their care, but it's not directly related to the client's autonomous decision-making about their treatment.
Correct Answer is C
Explanation
A. The partner has placed locks at the top of the doors leading to the outside:
Explanation: Placing locks at the top of doors leading outside is a safety measure to prevent the person with Alzheimer's disease from wandering or getting lost. While this does show that the partner is taking proactive steps to ensure the client's safety, it is not necessarily indicative of caregiver role strain.
B. The partner has hired a house cleaner:
Explanation: Hiring a house cleaner can be a sign of caregiver role strain. Caregivers often become overwhelmed with the responsibilities of caring for a person with Alzheimer's disease, and hiring help for household tasks can be an indication that they are finding it challenging to manage everything on their own.
C. The partner has lost 20 lb in the past 2 months:
Explanation: Rapid weight loss can be a sign of caregiver stress or burnout. The emotional and physical demands of caring for a loved one with Alzheimer's disease can lead to neglect of one's own well-being, including proper nutrition and self-care.
D. The partner redirects the client when the client is frustrated:
Explanation: While redirecting the client when they're frustrated shows that the partner is using appropriate strategies to manage challenging behaviors associated with Alzheimer's disease, this observation doesn't necessarily indicate caregiver role strain.
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