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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Explanation
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B. Oxytocin is not used to prevent contractions; it is used to stimulate them, especially during labor.
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Correct Answer is C
Explanation
A. While hormonal contraceptives can affect blood pressure, the risk of significant hypertension is less immediate than thromboembolism.
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D. Osteoporosis is a long-term concern but is not an acute effect of combination birth control pills; monitoring for thromboembolism is more critical.