Author Question: During the administration of the abnormal involuntary movement scale, the nurse should a. have ... (Read 32 times)

Starlight · **on:** Jul 19, 2018

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.

Question 2

When an anorexic client is admitted for treatment, the milieu should provide (more than one answer
may be correct)

A. flexible meal times.
B. adherence to a selected menu.
C. observation during and after meals.
D. unscheduled weight checks.
E. monitoring during bathroom trips.
F. privileges correlated with affective display.

aloop · **Reply #1 on:** Jul 19, 2018

Answer to Question 1

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.

Answer to Question 2

B, C, E
Rationale: Priority milieu interventions support restoration of weight and normalization of eating
patterns. This requires close supervision of the client's eating and prevention of exercise, purging,
and so forth. Menus are strictly adhered to. Observation is maintained during and after meals to
prevent throwing away food or purging. All trips to the bathroom are monitored. Option A:
Mealtimes are precisely observed, not flexible. Option D: Weighing is performed on a regular
schedule. Option F: Privileges are correlated with weight gain and treatment plan compliance.