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 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.
Correct Answer is B
Explanation
A. Praise the client for looking at herself in a mirror.
While body image concerns are common in anorexia nervosa, praising the client for looking at herself in a mirror may inadvertently reinforce the focus on appearance and body image, which can be counterproductive.
B. Ask the client to agree to talk to a nurse whenever she feels the urge to exercise.
Explanation: For a client with anorexia nervosa, overexercising can be part of the unhealthy behaviors associated with the disorder. Collaborative communication is important in addressing and managing these behaviors. Asking the client to agree to talk to a nurse whenever the urge to exercise arises is a supportive approach. It allows the nurse to provide emotional support, explore the client's motivations and triggers for overexercising, and work together on finding healthier coping strategies.
C. Reprimand the client about the potential damage that has occurred due to overexercising her body.
Reprimanding the client may lead to feelings of guilt and shame, which are counterproductive in supporting recovery. A more empathetic and supportive approach is needed.
D. Restrict the client from being weighed.
Restricting the client from being weighed might exacerbate anxiety around weight gain and contribute to the client's preoccupation with weight. However, monitoring weight under the supervision of healthcare professionals is important in managing anorexia nervosa.
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