A nurse is assessing a client who has schizophrenia which has been treated with fluphenazine for several years. Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?
Shuffling gait
Sudden onset of high fever
Constant tapping of feet when sitting
Twisting tongue movements
The Correct Answer is D
A. A shuffling gait is more commonly associated with parkinsonism, a side effect of antipsychotic medications, rather than tardive dyskinesia.
B. A sudden onset of high fever could indicate neuroleptic malignant syndrome (NMS), which is a serious reaction to antipsychotic medications, not tardive dyskinesia.
C. Constant tapping of feet when sitting can indicate restlessness or akathisia, but it does not specifically represent tardive dyskinesia.
D. Twisting tongue movements are a classic manifestation of tardive dyskinesia, characterized by involuntary, repetitive movements of the face, tongue, and extremities, which may develop after long-term use of antipsychotic medications like fluphenazine.
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Correct Answer is A
Explanation
A. Following the insertion of the Nexplanon rod, it is important to inform the client that backup contraception methods are needed for the first 24 hours to ensure pregnancy prevention while the implant becomes effective.
B. While smoking cessation is advised due to the increased risk of thrombotic events with hormonal contraceptives, it is not the priority instruction immediately following the insertion of Nexplanon.
C. The statement regarding weight loss is incorrect; Nexplanon is more commonly associated with weight gain rather than loss, so advising clients on calorie consumption is misleading.
D. Although Nexplanon has a high efficacy rate in preventing pregnancy, stating a prevention rate of 100% is inaccurate and misleading, as no contraceptive method is completely foolproof.
Correct Answer is C
Explanation
A. Asking what the usual pill looks like may not provide clarity and does not address the client's concern directly.
B. While the statement is accurate, it does not provide the client with reassurance or address the reason for the difference in appearance.
C. This response acknowledges the client's concern, offers an explanation about variations in medication appearance due to different manufacturers, and reassures the client that it is the same medication prescribed.
D. Suggesting that the pill is from a different lot number does not address the fact that variations in appearance can occur due to different manufacturers, which is more common and relevant to the situation.