A nurse observes an older adult client who has been taking antipsychotic medications for 8 months. The client is smacking her lips and blinking her eyes rapidly. The nurse also observes a protruding tongue. Which action by the nurse would be most appropri
A) Ask whether the client has been experiencing side effects.
B) Contact the client's physician for a different medication order.
C) Document the client's symptoms of tardive dyskinesia.
D) Instruct the client to begin tapering the medication.
Ans: C
The nurse should document the symptoms of tardive dyskinesia, a chronic syndrome caused by long-term use. Asking the client whether she has been experiencing side effects would be inappropriate because the client is already exhibiting signs. Contacting the physician for a different medication implies that these effects can be reversed. Tardive dyskinesia is typically irreversible. It is not within the nurse's scope of practice to instruct the client to begin to taper the drug.
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