The spouse of a client on an antipsychotic medication asks the nurse why they routinely assess the client for movements, especially around the mouth and extremities. What nursing response is correct?
1. "Abnormal involuntary movements can be an irreversible side effect of antipsychotic medications."
2. "Antipsychotic medications can lead to this type of dystonia."
3. "Abnormal involuntary movements can be easily treated and less annoying to the client."
4. "Movements around the mouth herald the approaching medication tolerance that the client is developing."
1
Rationale: The nurse is assessing for tardive dyskinesia, an arrhythmic, involuntary movement that can be irreversible if not detected early. Antipsychotic medications do not lead to tolerance. Abnormal involuntary movements are not easily treated. Dystonia is a side effect characterized by muscle spasms.
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1. A 2. B 3. C 4. D