A patient diagnosed with schizophrenia has received fluphenazine decanoate twice a month for 3 years. The clinic nurse's notes that the patient grimaces and is constantly smacking his lips. The patient's neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect?
Tourette's syndrome
Agranulocytosis
Anticholinergic effects
Tardive dyskinesia
The Correct Answer is D
A. This disorder is characterized by sudden, rapid, recurrent motor movements and vocal tics, not slow, writhing movements caused by long-term antipsychotic use.
B. This is a dangerous reduction in white blood cells, typically presenting with fever, sore throat, or infections, not abnormal involuntary movements.
C. Anticholinergic side effects include dry mouth, blurred vision, constipation, urinary retention, not the repetitive, involuntary movements seen here.
D. This condition is a late-onset side effect of long-term use of antipsychotics, especially first-generation drugs like fluphenazine. It presents as grimacing, lip smacking, and slow, writhing movements of the neck and shoulders, consistent with the patient’s symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Voluntary admission does not remove a patient’s right to refuse treatment; informed consent is still required for all medications and procedures.
B. Clients admitted voluntarily retain the right to make decisions about their care, including providing informed consent for treatments and medications. This statement accurately reflects the client’s rights.
C. Healthcare providers are not allowed to disclose patient admission information without consent; confidentiality is maintained.
D. Voluntary patients have the right to request discharge, usually with a short notice period, even before a formal discharge summary is completed.
Correct Answer is A
Explanation
A. The highest priority is monitoring for refeeding syndrome, a potentially fatal complication when nutrition is reintroduced after prolonged starvation. It causes severe electrolyte shifts (especially hypophosphatemia, hypokalemia, and hypomagnesemia) and cardiac/respiratory complications.
B. Important, but not priority. Therapeutic communication builds trust, but physiological safety is the first concern.
C. Help the patient balance energy expenditures with caloric intake. – Useful long-term. This supports recovery but is not immediately life-saving.
D. Assess for depression and anxiety. – Necessary, but secondary. Mental health evaluation is part of holistic care, but immediate physical safety takes precedence.
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