The nurse is caring for a patient who is being treated with antipsychotic medications. As part of the plan of care, the nurse monitors the patient for dyskinesia. What would the nurse assess with dyskinesia?
Involuntary movements of the mouth and tongue
Abnormal breathing
Migraine headache, hypertension
Severe flushing, headache, and tremors
The Correct Answer is A
A. Involuntary movements of the mouth and tongue: Dyskinesia, particularly tardive dyskinesia, involves involuntary movements, often of the mouth, tongue, and sometimes other parts of the body.
B. Abnormal breathing: This is not a typical manifestation of dyskinesia.
C. Migraine headache, hypertension: These symptoms are not associated with dyskinesia.
D. Severe flushing, headache, and tremors: These symptoms do not describe dyskinesia, although tremors can be seen in other movement disorders.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Prevention of infection and promote healing. Debridement helps remove dead tissue, which prevents infection and promotes healing.
B. Promoting movement in the affected area: While movement is important, debridement is primarily for removing necrotic tissue to prevent infection.
C. To increase the effectiveness of the skin graft: Debridement does help prepare the wound bed for grafting, but its main purpose is infection control and healing.
D. Promoting suppuration of the wound: Suppuration is not a goal of debridement; it is about cleaning the wound and preventing infection.
Correct Answer is A
Explanation
A. Delirium: Delirium is characterized by acute confusion, disorientation, and altered mental status often due to severe infection or high fever.
B. Psychotic break: While hallucinations are a symptom, a psychotic break is generally a chronic mental health condition rather than an acute response to infection.
C. Possible stroke: Stroke symptoms usually involve sudden onset of neurological deficits rather than fever and hallucinations.
D. Anxiety disorder: Anxiety disorders do not typically cause such high fevers or acute hallucinations.
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