A client received maintenance doses of trifluoperazine (Stelazine) 30 mg po daily for 1.5 years. The
clinic nurse notes the client is grimacing and seems to be constantly smacking her lips.
Her neck and
shoulders twist in a slow, snakelike motion. The nurse should suspect the presence of
a. agranulocytosis.
b. tardive dyskinesia.
c. Tourette's syndrome.
d. anticholinergic effects.
B
Tardive dyskinesia is a neuroleptic-induced condition involving the face, trunk, and limbs.
Involuntary movements such as tongue thrusting; licking; blowing; irregular movements of the arms,
neck, and shoulders; rocking; hip jerks; and pelvic thrusts are seen. These symptoms are frequently
not reversible even when the drug is discontinued. The scenario does not present evidence consistent
with the other disorders mentioned. Option A: Agranulocytosis is a blood disorder. Option C:
Tourette's syndrome is a condition in which tics are present. Option D: Anticholinergic effects
include dry mouth, blurred vision, flushing, constipation, and dry eyes.
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The nurse prepares a 70-year-old client to begin hemodialysis. Before beginning treatment, which of the following immunizations is required?
A) Influenza B) Hepatitis A C) Hepatitis B D) Tetanus and diphtheria
The nurse is preparing a patient to go home. Which skill should the nurse use when preparing this patient?
1. Familiarity with adult learning principles 2. Ability to follow written orders 3. Ability to use critical thinking 4. Ability to support patient decision making
A nurse delegates the task of assisting patients with ambulation to a student nurse. The nurse intervenes when observing the student
1. Instructing the patient to move from supine to standing positions in stages. 2. Assisting the patient to a dangling position with his or her feet firmly on the floor. 3. Holding the transfer belt loosely near the patient's body while ambulating. 4. Raising the head of the bed and assisting the patient with sitting on the side of the bed.
Which of the following is a correct guideline to follow when providing a bed bath for a patient?
A) When cleaning the eye, move the washcloth from the outer to the inner aspect of the eye. B) Fold the washcloth like a mitt on your hand so that there are no loose ends. C) Clean the perineal area before cleaning the gluteal area. D) Change the bath water after washing each body part.