During the administration of the abnormal involuntary movement scale, the nurse should
a. have the client sit with hands over the head.
b. ask the client to protrude the tongue.
c. have the client lie prone on the floor.
d. direct the client to touch the nose with the tip of each finger.
ANS: B
The client is asked to protrude the tongue for several seconds to enable the nurse to assess for fine
movements of the tongue, a possible indicator of tardive dyskinesia related to long-term
phenothiazine therapy. Administration of the abnormal involuntary movement scale does not call for
any of the other client actions.
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