The nurse is concerned that a client being treated with ...

[skymedlock]

The nurse is concerned that a client being treated with antipsychotic medication for schizophrenia is developing extrapyramidal symptoms. Which assessment findings support the nurse's concern?
 
  Standard Text: Select all that apply.
  1. Neck spasms
  2. Fidgeting and rocking back and forth in the chair
  3. Shuffling gait
  4. Lip smacking and rapid eye blinking
  5. Diaphoresis and muscle rigidity

Question 2

During an assessment, the nurse determines a client is demonstrating symptoms of a psychosis. Which clinical manifestations did the nurse find during the assessment of this client?
 
  Standard Text: Select all that apply.
  1. The client says, The servants need to be disciplined.
  2. The client says, The voice told me to cut myself.
  3. The client laughs when asked about the health of a family member hospitalized for cancer treatment.
  4. The client asks to close the room door so that man can't get to me.
  5. The client says, I have not been able to get any sleep for months.

[CAPTAINAMERICA]

Answer to Question 1

Correct Answer: 1,2,3,4
Rationale 1: Acute dystonia involves severe muscle spasms of the neck.
Rationale 2: Akathisia, the inability to rest or relax, is a common extrapyramidal symptom.
Rationale 3: Parkinsonism induced by antipsychotic medications may include a shuffling gait.
Rationale 4: Tardive dyskinesia is characterized by involuntary lip smacking and rapid eye blinking.
Rationale 5: These are not extrapyramidal symptoms.
Global Rationale: Muscle spasms, akathisia, Parkinsonism, and tardive dyskinesia are all examples of extrapyramidal symptoms. Diaphoresis and muscle rigidity are not extrapyramidal symptoms.

Answer to Question 2

Correct Answer: 1,2,3,4
Rationale 1: This statement is an example of a grandiose delusion.
Rationale 2: This statement is an example of an auditory hallucination.
Rationale 3: During a psychotic episode, the client's mood and affect may vary widely and be inappropriate, such as laughing at sad events.
Rationale 4: This statement is an example of a delusion in which someone is trying to harm the client.
Rationale 5: The lack of sleep is not a symptom of psychosis.
Global Rationale: The lack of sleep is not a symptom of psychosis. All other findings indicate symptoms of psychoses including grandiose delusion, auditory hallucination, and inappropriate responses.

[skymedlock]

Gracias!

[ryansturges]

TYSM