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 C
Explanation
A. Hydrochlorothiazide is a thiazide diuretic that can be used for hypertension and edema but is not specifically indicated for open-angle glaucoma.
B. Furosemide is a loop diuretic used primarily for fluid overload conditions and does not have a specific role in the treatment of open-angle glaucoma.
C. Acetazolamide is a carbonic anhydrase inhibitor that reduces aqueous humor production and is specifically used to lower intraocular pressure in clients with open-angle glaucoma.
D. Spironolactone is a potassium-sparing diuretic used mainly for conditions like heart failure and hypertension, and it is not indicated for the treatment of open-angle glaucoma.
Correct Answer is B
Explanation
A. Chlorpheniramine is a first-generation antihistamine and may cause sedation and other side effects due to its ability to cross the blood-brain barrier.
B. Cetirizine is a second-generation antihistamine that is less likely to cause sedation and is used to relieve symptoms of allergic rhinitis.
C. Montelukast is a leukotriene receptor antagonist, not an antihistamine, and is used for allergic rhinitis and asthma.
D. Diphenhydramine is a first-generation antihistamine known for its sedative effects and is often used for allergies but is not classified as a second-generation antihistamine.