A nurse is collecting data from a client who is taking chlorpromazine. Which of the following findings should the nurse identify as extrapyramidal symptoms (EPS)? (Select all that apply.)

Impaired gait

Fidgeting behavior

Muscle contractions of the neck

Fluctuating vital signs

Sexual dysfunction

Answer and Explanation

Correct Answer : A,C

A.   Impaired gait is a classic extrapyramidal symptom, which includes issues like dystonia or bradykinesia.
B.   Fidgeting behavior is more related to anxiety or restlessness rather than EPS.
C.   Muscle contractions of the neck, known as torticollis, are common signs of EPS caused by antipsychotic medications such as chlorpromazine.
D.   Fluctuating vital signs are not directly linked to EPS but may indicate another underlying issue.
E.   Sexual dysfunction is a side effect of chlorpromazine but not classified as an EPS.

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Correct Answer is A

Explanation

A. The nurse’s primary concern is preventing the client from embarrassing herself due to the impulsive and disinhibited behaviors typical of a manic episode.
B. There is no indication that dancing is prohibited; the issue is with inappropriate behavior.
C. The focus of the action is not on sexual behavior but on ensuring the client is appropriately dressed in a social setting.
D. Following policy is important, but the nurse’s action is more about protecting the client from social
embarrassment.

A. pulse deficit B. diastolic C. auscultatory gap D. widened pulse pressure

Correct Answer is C

Explanation

A. A pulse deficit refers to a condition where there is a difference between the radial and apical pulse rates, not a phenomenon heard during blood pressure measurement.
B. Diastolic pressure is the point at which sounds fade away or become muffled, but the silence between sounds refers to a different concept, not the actual diastolic pressure.
C. An auscultatory gap is the term used to describe a silent interval between the systolic and diastolic sounds during blood pressure measurement. This can lead to inaccurately low readings if not identified.
D. A widened pulse pressure refers to a larger-than-normal difference between systolic and diastolic pressure, which is not related to the auscultatory silence.

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A nurse is collecting data from a client who is taking chlorpromazine. Which of the following findings should the nurse identify as extrapyramidal symptoms (EPS)? (Select all that apply.)

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Correct Answer is A

Explanation

If a silence is heard between sounds when auscultating blood pressure, it is termed a(n)

Correct Answer is C

Explanation

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