A nurse on a mental health unit observes a diagnosed schizophrenic patient on antipsychotics having an impaired gait and uncontrollable tremors. The nurse should recognize that which of the following adverse effects may be occurring?

Tardive dyskinesia.

Acute dystonia.

Pseudoparkinsonism.

Neuroleptic malignant syndrome.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Pseudoparkinsonism.

Choice A rationale:

Tardive dyskinesia is a long-term side effect of antipsychotic medications characterized by repetitive, involuntary movements, often around the mouth, such as lip-smacking, tongue protrusion, and chewing movements. It does not typically present with impaired gait and tremors.

Choice B rationale:

Acute dystonia involves sudden, severe muscle contractions, often affecting the neck, face, and back. Symptoms include twisting movements and abnormal postures, but it does not usually cause impaired gait and tremors.

Choice C rationale:

Pseudoparkinsonism is an adverse effect of antipsychotic medications that mimics the symptoms of Parkinson’s disease, including bradykinesia (slowness of movement), rigidity, tremors, and postural instability. The impaired gait and uncontrollable tremors observed by the nurse are characteristic signs of pseudoparkinsonism.

Choice D rationale:

Neuroleptic malignant syndrome is a rare but life-threatening reaction to antipsychotic medications. It presents with symptoms such as high fever, muscle rigidity, altered mental status, and autonomic dysfunction (e.g., unstable blood pressure, sweating). It does not typically present with impaired gait and tremors.

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Correct Answer is A

Explanation

Choice A rationale:

The statement "You are feeling very depressed. I felt the same way when I decided to leave my husband." is a non-therapeutic statement that demonstrates sympathy. The nurse is sharing personal experiences, which can shift the focus from the client's feelings to the nurse's own experiences.

Choice B rationale:

The statement "I can understand you are feeling depressed. It was a difficult decision. I'll sit with you." is a therapeutic response that offers support and empathy without diverting the focus to the nurse's experiences. The nurse's willingness to sit with the client is a positive aspect of this response.

Choice C rationale:

The statement "You seem depressed. It was a difficult decision to make. Would you like to talk about it?" is a therapeutic response that acknowledges the client's feelings, offers support, and invites further conversation. This response encourages the client to express themselves.

Choice D rationale:

The statement "I know this is a difficult time for you. Would you like medication for anxiety?" acknowledges the client's difficulties but immediately offers medication as a solution. While medication can be a valid option, it's important to prioritize open communication and emotional support before suggesting medication.

A. Administer medication to sedate the client. B. Call the family and ask them to stay with the client. C. Apply wrist and leg restraints to the client. D. Move the client to a room closer to the nurses' station.

Correct Answer is D

Explanation

Choice A rationale:

Administering medication to sedate the client is not the appropriate initial action. The client's confusion and restlessness could be due to various factors, and administering sedative medication without identifying the cause of these symptoms could lead to adverse effects or mask underlying issues.

Choice B rationale:

Calling the family to stay with the client might provide emotional support, but it doesn't directly address the client's safety needs. The client's increasing confusion and restlessness require a more immediate intervention to ensure their safety.

Choice C rationale:

Applying wrist and leg restraints should be a last resort and is not the appropriate initial action in this situation. Restraints should only be used if less restrictive interventions have failed and the client's safety is at risk. Restraints can lead to complications such as decreased mobility, skin breakdown, and increased agitation.

Choice D rationale:

Correct Choice Moving the client to a room closer to the nurses' station is the most appropriate action in this scenario. This intervention helps to increase the client's visibility and proximity to nursing staff, making it easier to monitor and address their needs promptly. It also promotes a safer environment while allowing the healthcare team to assess the underlying causes of the restlessness and confusion.

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A nurse on a mental health unit observes a diagnosed schizophrenic patient on antipsychotics having an impaired gait and uncontrollable tremors. The nurse should recognize that which of the following adverse effects may be occurring?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has made the decision to leave her alcoholic husband and reports feeling very depressed. Which of the following is a non-therapeutic statement by the nurse that demonstrates sympathy?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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