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.
You may also like to solve these questions
A nurse is preparing a patient for electroconvulsive therapy. Which of the following would the nurse include in the patient?s plan of care? Select all that apply.
- A. Ensuring that there is a signed informed consent on the patient?s chart
- B. Telling the patient he can have fluids but no food before the procedure
- C. Alerting the patient to the possibility of confusion after the treatment
- D. Informing the patient that he can leave his dentures in place for the treatment
- E. Ensuring that the patient is closely supervised for at least the first 12 hours afterward
Correct Answer: A,C,E
Rationale: ECT requires informed consent (A), warning about post-procedure confusion (C), and close supervision afterward (E) due to risks like disorientation. Patients must be NPO (no food or fluids) before ECT, and dentures must be removed to prevent airway obstruction, making B and D incorrect.
A patient who has been taking clozapine for 6 weeks visits the clinic complaining of fever, sore throat, and mouth sores. The nurse notifies the patient?s physician because the nurse suspects which of the following?
- A. Severe anemia
- B. Neuroleptic malignant syndrome
- C. Encephalitis
- D. Agranulocytosis
Correct Answer: D
Rationale: Fever, sore throat, and mouth sores in a patient taking clozapine suggest agranulocytosis, a serious side effect involving a dangerous drop in white blood cells, requiring immediate medical attention. Anemia, neuroleptic malignant syndrome, and encephalitis have different symptom profiles.
A patient with depression asks the nurse about possible herbal supplements. Which of the following would the nurse identify as being commonly used?
- A. Valerian
- B. St. John?s wort
- C. Kava
- D. Melatonin
Correct Answer: B
Rationale: St. John?s wort is commonly used for mild to moderate depression due to its serotonergic effects. Valerian and melatonin are used for sleep, and kava for anxiety, not primarily for depression.
A nurse is working as part of a team involved with the testing of a new psychiatric medication. The drug is currently being used in multiple clinical trials at various different sites. The nurse is engaged in which phase of testing?
- A. Phase I
- B. Phase II
- C. Phase III
- D. Phase IV
Correct Answer: C
Rationale: Phase III clinical trials involve testing a drug in multiple sites with larger populations to confirm efficacy and safety, matching the scenario. Phase I tests safety in small groups, Phase II assesses efficacy in a limited population, and Phase IV occurs post-market.
After teaching a patient who is prescribed imipramine about the drug, the nurse determines that the teaching was effective when the patient states which of the following?
- A. I need to be careful because the drug can make me sleepy.
- B. I don?t have to worry about getting dizzy when I get up from lying down.
- C. I might notice some excess saliva in my mouth at different times.
- D. I need to avoid foods with fiber because diarrhea can occur.
Correct Answer: A
Rationale: Imipramine, a tricyclic antidepressant, commonly causes sedation, so the patient?s statement about sleepiness indicates effective teaching. Dizziness (orthostatic hypotension) is a concern, dry mouth (not excess saliva) is typical, and constipation (not diarrhea) is a side effect, making other options incorrect.