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 ["B","C","E","F"]
Explanation
A. Bruising is typically related to anticoagulant effects or blood disorders and not directly tied to the desired effects of PTU.
B. Improved sleep is an indicator that hyperthyroidism symptoms, such as insomnia, are being managed effectively.
C. A decrease in anxiety can suggest effective management of hyperthyroidism, as anxiety is a common symptom of this condition.
D. Weight loss or inability to gain weight is usually a symptom of hyperthyroidism, so this statement would indicate that PTU is not achieving the desired effect.
E. A return to regular menstruation can indicate improved thyroid function, as hyperthyroidism can disrupt menstrual cycles.
F. Reduced heart rate and the absence of palpitations suggest effective management of hyperthyroidism symptoms, indicating the drug is having the desired effect.
Correct Answer is C
Explanation
A. LABAs can help prevent asthma attacks, including those triggered by exercise, so this statement is accurate and does not indicate a need for further education.
B. LABAs may cause side effects like an increased heart rate, which the client correctly recognizes.
C. LABAs are not intended for immediate relief of asthma symptoms; they are for long-term control. A short-acting beta2-agonist (SABA) should be used for acute symptoms, indicating this client needs further education.
D. Over time, tolerance can develop with some medications, and this understanding is accurate, so it does not indicate a need for additional teaching.