An older male adult is taking aripiprazole (Abilify) for agitation. Which patient assess-ment is the nurse's priority to prevent catastrophic effects of the medication?
a. Oral and facial dyskinesia
b. Mask facies, shuffling gait
c. Muscle spasms of the face
d. Repetitive aimless walking
A
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A Correct. This individual is taking an atypical antipsychotic agent to control manic episodes of dementia. Although these agents are less likely to cause tar-dive dyskinesia (TD), the nurse monitors for the associated abnormal movements of TD including oral and facial dyskinesia, impairment in the ability to execute voluntary facial movement. The nurse reports this immediately to stop therapy and prevent an irreversible condition.
B Incorrect. Mask facies, having a masklike appearance, and shuffling gait are parkinsonian side effects of antipsychotic agents and can be improved with an-tiparkinsonian agents.
C Incorrect. Muscle spasms of the face, tongue, neck, and back are adverse effects of antipsychotic agents usually seen within the first 5 days of therapy. They are potential indicators of acute dystonia and can be improved with antiparkinsonian agents.
D Incorrect. Motor restlessness is an adverse effect of antipsychotic agents and is characteristic of akathisia.
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