Author Question: A 62-year-old woman has been taking chlorpromazine (Thorazine) since she was in her early 20s. Which ... (Read 50 times)

fahad · **on:** Jul 19, 2018

A 62-year-old woman has been taking chlorpromazine (Thorazine) since she was in her early 20s. Which of the following assessment findings would signal the nurse to the possible presence of tardive dyskinesia (TD)?

A) The client begins alluding to visual hallucinations for the first time in several years.
B) The client frequently smacks her lips and chews without food.
C) The client develops exophthalmos (bulging eyes).
D) The client begins repeating nonsensical words while at rest.

Question 2

While conducting an admission assessment with Ron, a psychiatricmental health client, he states that he hears the voice of God in his head and the voice is telling him that he is worthless. What would the nurse document this symptom as?

A) A hallucination
B) A delusion
C) Thought broadcasting
D) Thought insertion

Edwyer · **Reply #1 on:** Jul 19, 2018

Answer to Question 1

Ans: B
Feedback:
TD is a type of EPS characterized by abnormal, involuntary, irregular, choreoathetoid (writhing) movements, which may include lip smacking, neck twisting, facial grimacing, and chewing without food. The other listed assessment findings are not suggestive of TD.

Answer to Question 2

Ans: A
Feedback:
Hallucinations are sensory perceptions with a compelling sense of reality but no actual objective basis. During auditory hallucinations (the most common form), clients may hear the voice of God or close relatives, two or more voices with a running commentary about the client's behavior, or voices that command certain acts. Usually the voices are obscene, accusatory, or insulting. They may call clients names and make nasty remarks.