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NurseDive Free Nursing Practice Question
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.)
A. Fine hand tremors and pill rolling
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: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 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
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.
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Full Explanation
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.
Similar Questions
A nurse is discussing treatment of depressive disorders with a client who has major depression. Which of the following client statements indicates understanding of the teaching?
A. I can be on my antidepressant taking three to five days to be effective
Antidepressants usually take several weeks to start taking effect, so the statement "I can be on my antidepressant taking three to five days to be effective" is not correct.
B. I can cure my depression by thinking positive thoughts."
While positive thinking can play a role in managing mood, depression is a complex disorder that often requires more than just positive thoughts to treat. The statement "I can cure my depression by thinking positive thoughts" oversimplifies the condition.
C. I will attend psychotherapy to help manage my depression,"
"I will attend psychotherapy to help manage my depression."Explanation: Depressive disorders, including major depression, are complex conditions that typically require a multifaceted approach to treatment. Psychotherapy, also known as talk therapy, is an important component of treating depression. It involves working with a trained therapist to explore and address the thoughts, feelings, and behaviors contributing to the depression. Psychotherapy can help individuals develop coping strategies, improve problem-solving skills, and gain insight into their condition.
D. "I need to make a voluntary choice to stop feeling depressed."
Depression is not something that can be simply chosen to be stopped voluntarily. It is a mental health disorder that often requires professional treatment and support. The statement "I need to make a voluntary choice to stop feeling depressed" does not accurately capture the nature of depression.
Full Explanation
A. Antidepressants usually take several weeks to start taking effect, so the statement "I can be on my antidepressant taking three to five days to be effective" is not correct.
B. While positive thinking can play a role in managing mood, depression is a complex disorder that often requires more than just positive thoughts to treat. The statement "I can cure my depression by thinking positive thoughts" oversimplifies the condition.
C. "I will attend psychotherapy to help manage my depression."
Explanation:
Depressive disorders, including major depression, are complex conditions that typically require a multifaceted approach to treatment. Psychotherapy, also known as talk therapy, is an important component of treating depression. It involves working with a trained therapist to explore and address the thoughts, feelings, and behaviors contributing to the depression. Psychotherapy can help individuals develop coping strategies, improve problem-solving skills, and gain insight into their condition.
D. Depression is not something that can be simply chosen to be stopped voluntarily. It is a mental health disorder that often requires professional treatment and support. The statement "I need to make a voluntary choice to stop feeling depressed" does not accurately capture the nature of depression.
A nurse manager on a mental health unit is discussing involuntary admissions during a staff meeting. Which of the following statements should the manager include in the discussion?
A. "Clients who are involuntarily admitted have the right to informed consent."
Clients who are involuntarily admitted to a mental health unit retain their rights, including the right to informed consent. This means they must be informed about their treatment, including medications, procedures, and potential risks, and they have the right to accept or refuse treatment, unless a court order states otherwise.
B. "Clients should be given medications even if they refuse them."
Involuntary admission does not automatically mean forced treatment. Clients can refuse medications, unless they are deemed a danger to themselves or others, in which case a court order may be obtained to administer medication.
C. "The laws regarding restraints are different for clients who are admitted involuntarily."
Restraint laws apply equally to all clients, regardless of admission status. Restraints must always be used as a last resort and require a provider’s order, regular assessments, and documentation.
D. "Clients who are admitted involuntarily can be hospitalized for as long as the provider deems necessary."
Involuntary hospitalization has legal time limits, and court review is required for extended hospitalization. The length of stay varies based on state laws and judicial rulings.
Full Explanation
A. Clients who are involuntarily admitted to a mental health unit retain their rights, including the right to informed consent. This means they must be informed about their treatment, including medications, procedures, and potential risks, and they have the right to accept or refuse treatment, unless a court order states otherwise.
B. Involuntary admission does not automatically mean forced treatment. Clients can refuse medications, unless they are deemed a danger to themselves or others, in which case a court order may be obtained to administer medication.
C. Restraint laws apply equally to all clients, regardless of admission status. Restraints must always be used as a last resort and require a provider’s order, regular assessments, and documentation.
D. Involuntary hospitalization has legal time limits, and court review is required for extended hospitalization. The length of stay varies based on state laws and judicial rulings.
A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority?
A. Determining if the client has psychotic thinking
The highest priority assessment in this situation is to determine if the client has psychotic thinking. Psychotic thinking can indicate a severe mental health condition that requires immediate attention and intervention. If the client is experiencing psychotic symptoms, they might be at risk of harming themselves or others. Identifying and addressing psychotic thinking is crucial to ensure the safety and well-being of the client and those around them.
B. Asking the client to identify the cause of the crisis
While understanding the cause of the crisis is important for providing appropriate care, it is not the highest priority. Psychotic thinking or risk of harm takes precedence over understanding the cause.
C. Identifying the client's coping skills
Coping skills are important for managing the crisis and promoting the client's well-being, but assessing for psychotic thinking and immediate safety concerns comes before evaluating coping skills.
D. identifying the client's support systems
Support systems are valuable for the client's overall recovery, but they are not as time-sensitive as assessing for psychotic thinking or imminent safety risks. Identifying support systems can come after addressing the immediate concerns.
Full Explanation
The highest priority assessment in this situation is to determine if the client has psychotic thinking. Psychotic thinking can indicate a severe mental health condition that requires immediate attention and intervention. If the client is experiencing psychotic symptoms, they might be at risk of harming themselves or others. Identifying and addressing psychotic thinking is crucial to ensure the safety and well-being of the client and those around them.
B. Asking the client to identify the cause of the crisis.
While understanding the cause of the crisis is important for providing appropriate care, it is not the highest priority. Psychotic thinking or risk of harm takes precedence over understanding the cause.
C. Identifying the client's coping skills.
Coping skills are important for managing the crisis and promoting the client's well-being, but assessing for psychotic thinking and immediate safety concerns comes before evaluating coping skills.
D. Identifying the client's support systems.
Support systems are valuable for the client's overall recovery, but they are not as time-sensitive as assessing for psychotic thinking or imminent safety risks. Identifying support systems can come after addressing the immediate concerns.