Nokea
The nurse observes an older adult patient who has been taking antipsychotic medications for 8 months. The patient is smacking her lips and blinking her eyes rapidly. The nurse also observes a protruding tongue. Which action by the nurse would be most appropriate?
- A. Ask if the patient has been experiencing side effects.
- B. Contact the patient?s physician for a different medication order.
- C. Document the patient?s symptoms of tardive dyskinesia.
- D. Instruct the patient to begin tapering off the medication.
Correct Answer: C
Rationale: Lip smacking, rapid blinking, and tongue protrusion indicate tardive dyskinesia, a serious side effect of long-term antipsychotic use. Documenting these symptoms is the most appropriate initial action to ensure accurate reporting and prompt physician review. Asking about side effects is vague, contacting the physician follows documentation, and tapering is premature without medical orders.
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A patient is experiencing hallucinations and delusions. The nurse would expect the physician to order which class of drug?
- A. Mood stabilizer
- B. Antipsychotic
- C. Antianxiety agent
- D. Stimulant
Correct Answer: B
Rationale: Hallucinations and delusions are hallmark symptoms of psychosis, treated primarily with antipsychotics. Mood stabilizers address bipolar disorder, antianxiety agents treat anxiety, and stimulants are used for ADHD, not psychosis.
A nurse administers a prescribed dose of lithium at 8 PM. The nurse would schedule a specimen to be obtained for a blood level at which time?
- A. 10:00 PM
- B. 12:00 AM
- C. 4:00 AM
- D. 8:00 AM
Correct Answer: D
Rationale: Lithium levels are typically drawn 12 hours after the last dose to measure trough levels, ensuring steady-state concentration. A dose at 8 PM would require a blood draw at 8 AM. Earlier times (10 PM, 12 AM, 4 AM) do not align with this timing.
A nurse is performing an admission assessment. The patient complains that it has been taking larger and larger amounts of medication to get the desired effect. Based on this information, the nurse interprets this as suggesting which of the following?
- A. Desensitization
- B. Tolerance
- C. Therapeutic index
- D. Toxicity
Correct Answer: B
Rationale: Tolerance occurs when a patient requires increasing doses of a medication to achieve the same effect, as described. Desensitization is a broader term, therapeutic index measures safety margins, and toxicity indicates harmful effects, not increased dose requirements.
A hospitalized patient who has been taking an antipsychotic medication for 2 weeks begins pacing and walking throughout the unit. He tells the nurse that he cannot sit still. The nurse documents this finding as which of the following?
- A. Akinesia
- B. Dystonia
- C. Pseudoparkinsonism
- D. Akathisia
Correct Answer: D
Rationale: Akathisia is characterized by restlessness and an inability to sit still, common with antipsychotics. Akinesia involves reduced movement, dystonia causes muscle spasms, and pseudoparkinsonism mimics Parkinson?s symptoms like tremor, not restlessness.
A patient receiving an antipsychotic agent develops acute extrapyramidal symptoms. Which response by the nurse would be most appropriate?
- A. These symptoms are not real; the medication makes your brain think they are real.
- B. You have developed an allergy to the medication, so we need to change it.
- C. These are the results of the drug that can be treated; your illness is not getting worse.
- D. The sunlight together with the medication has caused these symptoms; just stay indoors.
Correct Answer: C
Rationale: Extrapyramidal symptoms (EPS) are treatable side effects of antipsychotics, not indicative of worsening illness. The nurse?s response should reassure the patient and explain that EPS can be managed. Denying symptoms, suggesting an allergy, or blaming sunlight are incorrect and nontherapeutic.