A nurse is assessing a client who has schizophrenia and has been on long-term treatment with chlorpromazine. He notes the client is experiencing some involuntary movements of the tongue and face. The nurse should suspect the client has developed which of the following adverse effects?
Akathisia
Tardive dyskinesia
Dystonia
The Correct Answer is B
Choice A reason: Akathisia:
Akathisia is characterized by a feeling of inner restlessness and an inability to stay still. It often manifests as constant movement, such as pacing or fidgeting. While akathisia is a common side effect of antipsychotic medications, it does not typically involve involuntary movements of the tongue and face.
Choice B reason: Tardive dyskinesia:
Tardive dyskinesia is a serious and often irreversible side effect of long-term antipsychotic use, including chlorpromazine. It is characterized by involuntary, repetitive movements, particularly of the face, tongue, and jaw. These movements can include lip smacking, tongue protrusion, and grimacing. This condition is a result of prolonged dopamine receptor blockade in the brain.
Choice C reason: Dystonia:
Dystonia involves sustained muscle contractions that cause twisting and repetitive movements or abnormal postures. It can affect any part of the body, including the neck, face, and limbs. While dystonia can be a side effect of antipsychotic medications, it typically presents as muscle spasms rather than the repetitive, involuntary movements seen in tardive dyskinesia.
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Correct Answer is A
Explanation
Choice A reason: WBC count:
An elevated white blood cell (WBC) count is a common indicator of infection. The body produces more white blood cells to fight off infections, making this a key marker for identifying infections in patients with pressure ulcers. Monitoring WBC count helps in assessing the presence and severity of an infection, guiding appropriate treatment.
Choice B reason: BUN:
Blood urea nitrogen (BUN) levels are used to assess kidney function and hydration status. Elevated BUN levels can indicate dehydration or kidney dysfunction but are not specific indicators of infection. While important for overall health assessment, BUN is not directly related to detecting infections in pressure ulcers.
Choice C reason: Potassium:
Potassium levels are crucial for maintaining normal cellular function, particularly in the heart and muscles. Abnormal potassium levels can indicate issues such as kidney dysfunction or electrolyte imbalances but do not specifically indicate infection. Monitoring potassium is important for overall health but not for diagnosing infections in pressure ulcers.
Correct Answer is B
Explanation
Choice A reason:
Wiping from back to front is incorrect and can lead to contamination of the urine sample with bacteria from the anal area. The correct method is to wipe from front to back to reduce the risk of contamination.
Choice B reason:
Urinating a small amount in the toilet before collecting the sample is the correct procedure for obtaining a midstream urine specimen. This helps to flush out any bacteria or contaminants from the urethra, ensuring that the sample collected is as clean as possible.
Choice C reason:
Letting the urine cool to room temperature before sending it to the lab is incorrect. Urine samples should be sent to the lab as soon as possible after collection to ensure accurate results. If there is a delay, the sample should be refrigerated.
Choice D reason:
It is generally recommended to avoid collecting a urine sample during menstruation, as menstrual blood can contaminate the sample and affect the test results.