A client with a diagnosis of schizophrenia

A client with a diagnosis of schizophrenia has been mute and in bed with almost no movement for several days prior to admission. Upon arrival to the unit, the client refuses to eat and drink and lays in bed facing the wall without moving or responding to the nurse. Which nursing action takes the highest priority? Approaching the client every hour to offer food and fluids. Talking about non-treatment related topics to build trust and rapport. Initiating one to one monitoring for safety. Assessing the client for fluid volume deficit. When evaluating outcomes for client with a diagnosis of psychosis being treated with haloperidol (Haldol), which symptoms would the nurse expect to see improvements in? Select all that apply. Social interaction Emotional responsiveness Distorted thoughts Cognitive functioning Hallucinations The nurse is reviewing medication administration record (MAR) for clients diagnosed with mental health issues. Which statement indicates the client is likely to have the greatest risk for metabolic syndrome? Client taking long-acting risperidone (Risperdal: Consta) and having history of medication compliance. Client taking Lithium carbonate (Eskalith) and aripiprazole (Abilify) Client taking Sertraline (Zoloft) and benztropine (Cogentin) Client taking Olanzapine (Zyprexa) and having family history of Diabetes Mellitus A client who was admitted to the hospital on a involuntary basis declines to take a new antidepressant medication ordered by the provider. The client states, “No one told me about this medication. I want to speak with the doctor before I take this” Which intervention by the nurse is most appropriate? Give the medication via injection since involuntary clients do not have the right to refuse medication. Allow the client to decline the medication and document the client’s reason for refusal and statements in the medical record. Tell the client that the medication is necessary to get better and ask the client, “Don’t you want to get better?” Crush the medication and then sprinkle it into the client’s food when the breakfast trays are delivered to the unit. After assessing a client prescribed quetiapine (Seroquel), the nurse identifies that the client is at risk for injury related to sedation from this medication. Which nursing intervention best addresses the identified nursing concern? Allowing the client time to adjust to the increased level of sedation. Asking the provider to change this medication to once daily dosing. Encouraging the client to increase fluid intake. Removing clutter from the environment. A client has been drinking a liter of vodka daily for the past 3 months. Which medication would the nurse expect to administer to support the client safely withdrawing from alcohol? Naltrexone (Revia) Alprazolam (Xanax) Chlordiazepoxide (Librium) Acamprosate (Campral) Which of the following nursing action is LEAST relevant when restraints are used? The nurse confirms first whether the client is voluntarily or involuntarily committed. The nurse coordinates an in-person evaluation within one hour of the initiation of the restraints. The nurse explores alternatives to minimize the use of restraints. The nurse considers whether the use of restraints is the least restrictive measure possible given the situation. Which of the following nursing action is LEAST relevant when restraints are used? The nurse confirms first whether the client is voluntarily or involuntarily committed. The nurse coordinates an in-person evaluation within one hour of the initiation of the restraints. The nurse explores alternatives to minimize the use of restraints. The nurse considers whether the use of restraints is the least restrictive measure possible given the situation. The nurse is assessing a client and suspects that the client has a diagnosis of a Cluster A personality disorder. Which data would lead the nurse to this assessment? Select all that apply. The client describes feeling different and more important than others with easily shifting mood. The client states, “I let others make decisions for me” and avoids responsibility. The client reports difficulty understanding the emotions of others leading to difficulty working with others. The client presents as tense and reports avoiding interactions with others. The client reports having a “sixth sense” and states, “People avoid me and think I am strange.” The nurse is working with a client with a diagnosis of antisocial personality disorder. The client has been threatening others on the unit and demands to be released immediately The client states, “If you don’t let me out of here, I will hurt you. It’s your choice.” Which response by the nurse is most appropriate? “How will you feel if you hurt someone? I am sure that you feel guilty about your behavior later.” “Tell me about how you are feeling right now? Do you really want to scare the other clients here on the unit?” “Let’s talk about your fears about being here in the hospital. How can we help you to feel safe here?” “If you harm anyone here, we will have to call the police and your probation officer. The nurse is teaching the student about relevant laboratory tests with medications for the treatment of Bipolar Disorder. Following the teaching, the student recognizes that which laboratory tests are indicated for a client prescribed Valproic Acid (Depakote)? Select all that apply. Kidney function tests Absolute neutrophil count (ANC) Serum Depakote level Platelet count Liver function tests During an admission interview, the client tells the nurse, “I have to increase my dose of Oxycodone because the smaller dose just wasn’t doing it for me anymore.” What assessment would the nurse make based upon the client’s statement? The client is in withdrawal from opiates. The client is experiencing tolerance. The client is co-dependent and abuses prescription medication. The client is in denial about substance use issues. The nurse is working with a client in restraints for the first time after starting a new job on an inpatient psychiatric unit. Which statements by the nurse indicate an understanding of restraint use in the mental health setting? Select all that apply. “Restraints are discontinued as soon as it is safe to do so.” “Restraints are an important part of the treatment plan for individuals with self harm behavior.” “Restraints are indicated only for imminent risk of harm to self or others.” “Debriefing with the client is necessary after any use of restraints.” “Restraint orders are time limited and PRN restraint orders are not permitted.” During an admission interview, the client tells the nurse, “I have to increase my dose of Oxycodone because the smaller dose just wasn’t doing it for me anymore.” What assessment would the nurse make based upon the client’s statement? The client is in withdrawal from opiates. The client is experiencing tolerance. The client is co-dependent and abuses prescription medication. The client is in denial about substance use issues. A disoriented, unkempt, and malnourished elderly individual was found in Lake View Cemetery and is brought to an emergency department by police. The client keeps yelling. “I don’t belong here. I am not crazy! I have to go!” Which would be the likely reason to initiate involuntary commitment for this client? Grave disability Property damage Harm to self Harm to others Unless state law is more restrictive, The Joint Commission (JCAHO) requires orders for restraint or seclusion must be renewed every; Maximum——- hour(s) for adults; Maximum—— hour(s) for client 9-17 years; and Maximum- hour(s) for clients younger than 9 years old. Choose the correct combination of number of hours on each blank. 6-3-1 8-4-2 1-4-4 4-2-1 When working with a client with a diagnosis of Borderline Personality Disorder. which interventions would be most appropriate for the nurse to include in the plan of care? Select all that apply. Educating the client about the use of journaling to allow expression of feelings. Focusing on explaining the consequences for behavior. Ensuring safety through ongoing assessment of suicidself-harmf harm risk. Assigning the client to work with consistent staff whenever possible Providing clear structure and consistency. A client is prescribed scheduled clonazepam (Klonopin) 1mg po TID for anxiety and agitation. The client is also prescribed clonazepam (Klonopin) 0.5mg po q4hrs PRN. Maximum daily dose of clonazepam (Klonipin) is 5mg. How many PRN doses can the client take in 24 hours without exceeding the total maximum daily dose? 2 doses 3 doses 6 doses 4 doses A client presents as pessimistic and verbalizes low self worth and profound difficulty making decisions. The client avoids taking responsibility and has a behavioral pattern of “suffering in silence.” The nurse assesses that the client is likely experiencing a personality disorder in which cluster? Cluster B Cluster C Cluster A A client is taking the following medications: Perphenazine (Trilafon) 4mg po TID Valproic Acid (Depakote) 500mg po BID Benztropine (Cogentin) 1mg4 hours PRN q 4hours for dystonia Trazadone 50mg po PRN QHS for insomnia Which assessment by the nurse indicates the need for benztropine(Cogentin)? The client reports “I feel so depressed. I wish I would feel better.” and isolates in room refusing groups. The client states, “I think I am getting a rash.” and the nurse notes irritated/reddened areas on the client’s torso. The client is having increased auditory hallucinations and states, “The voices tell me to hurt myself.” The client is experiencing stiffness and tightness in the neck muscles and reports. “I cannot move my neck.” The nurse who administers chlorpromazine (Thorazine) should be ready to explain to a client that the medication… stimulates alpha 2 adrenergic receptors in the prefrontal cortex. blocks serotonin receptors making serotonin less available. stabilizes dopamine and serotonin through partial agonism. blocks dopamine receptors making dopamine less available. The nurse is educating the client about the timing of blood draws for ongoing Lithium levels. Which statement best demonstrates the client’s understanding of the teaching? “I will go to the lab for my blood draw on my lunch break. I will take my morning dose of Lithium as usual.” “I will go to the lab to have my blood checked in the morning before I take my morning dose of Lithium.” “I will skip my morning dose of Lithium and get my blood drawn at lunch or on my way home in the evening.” “I will have my blood draw in the evening after work and I will continue to take my Lithium on my regular schedule.” During the admission interview, a homeless client with schizophrenia tells the nurse that she has been infested with bugs placed in her tent by the people trying to kill her. Which is the priority nursing intervention with this client? Validate the client’s feelings and assure her that she is safe. Administer a prn of the prescribed Haldol. Examine the client for body lice. Obtain an order from the provider for a urine for toxicology. The nurse is educating a client who has agreed to a trial of Long-Acting Injectable aripiprazole (Abilify). Which statement by the client indicates that the teaching has been effective? “The injectable aripiprazole (Abilify) is way more effective than the pills so I will never hear voices again.” “The injectable aripiprazole (Abilify) has no risks of stiffness which I experienced when I took the oral pills.” “I will not be likely to take oral aripiprazole (Abilify) as long as I keep getting the injections.” “The side effects of long-lasting injectable aripiprazole (Abilify) are different from the side effects I have with the pills.” The nurse is working with a client who drinks alcohol daily and has been doing this for several years. The client is now in treatment and has safely detoxed. The client begins to present with problems with balance as well as memory impairment and acute confusion. The nurse assesses that the client may be experiencing? Alcohol withdrawal Alcoholic hallucinosis Delirium tremens (DTs) Wernicke’s encephalopathy During an admission interview, the client tells the nurse, “I’ve had enough of this marriage. I feel like hiring a hit man to this woman” Which nursing action is most appropriate? The nurse maintains confidentiality witcontinuesient and continue to work with the client to resolve feelings of anger towards the wife. The nurse immediately notifies the police and contacts the wife to suggest she obtain a restraining order. The nurse encourages the client to talk with the psychiatrist about anger management. The nurse communicates what the client said to the care team and check’s the agency policy about informing the wife. A client with a personality disorder tells the nurse “I thought my psychiatrist was the best doctor in the world. Now, I HATE her! She’s dumping me to go on vacation. But you are the best nurse I have ever had.” Which term best describes the client’s behavior? Projection Regression Splitting Reaction Formation During an admission interview, the client tells the nurse, “I’ve had enough of this marriage. I feel like hiring a hit man to this woman.” Which nursing action is most appropriate? The nurse maintains confidentiality with the client and continue to work with the client to resolve feelings of anger towards the wife. The nurse immediately notifies the police and contacts the wife to suggest she obtain a restraining order. The nurse encourages the client to talk with the psychiatrist about anger management. The nurse communicates what the client said to the care team and check’s the agency policy about informing the wife. The team is considering initiation of Lithium for a client who was admitted for treatment of an initial manic episode. The client was admitted two days ago and has not slept since admission and is very intrusive with other clients on the unit. Which laboratory tests would the nurse expect to see ordered prior to the initiation of Lithium therapy? Select all that apply. Creatinine BUN Absolute Neutrophil Count (ANC) Hematocrit Liver function tests The mother of an 18 year old client who was admitted to the hospital for the first time with a diagnosis of rule out schizophrenia calls the unit to ask about the status of her son and to speak to him. The client has refused to sign a release of information and states, “Don’t tell anyone I am here. They will kill me if they know.” The mother is crying on the phone and tells the nurse. “I just need to know that he is okay.” Which response by the nurse is most appropriate? “I cannot confirm or deny if that individual is a client here.” “You must be so worried. Let me see if he will take your call. “I will take a message and tell him that you called.” “He is refusing all calls right now. He is pretty paranoid.” A client is being treated with Phenelzine (Nardil) after trials on two SSRIs and an SNRI which were not effective. The nurse has done teaching with the client about precaution with Phenelzine (Nardil). Which client statement indicates that the teaching has been effective? “I will be cautious of ingredients in food and I will avoid processed foods such as aged cheeses and salami.” “If I notice any unusual movements or stiffness while I am taking this medication, I will contact my provider immediately.” “I will need to have my blood checked weekly for the first six months that I am prescribed this medication.” “I will try to avoid getting overheated and sweating excessively since that will increase the risk of toxicity with this medication.” Which client is most likely to have limitations on the right to refuse medications in the mental health setting? An agitated client who is yelling and pacing on the unit. A client has been declared incompetent by the court. A client admitted on an involuntary basis with past aggression in the community. A client who has a history of lack of adherence with Lithium who is currently experiencing mania. A new nurse has accepted a job on a unit working with individuals with addiction issues. Prior to the start date, the nurse would likely consider these questions to promote self Awareness. Select all that apply. “What causes some people to have problems with alcohol and other substances?’ “Do I feel comfortable with my own use of alcohol?” “Has the use of alcohol (by me or others) affected my life in any way?” “Who is responsible when people abuse drugs and alcohol?” “When do I drink and what are my reasons for using alcohol?” A new nurse is starting a job on a unit that frequently treats clients with personality disorder diagnoses. Which treatment outcome would be most appropriate for the nurse to anticipate when working with this population? To decrease the amount of neurotransmitters at receptor sites. To stabilize symptoms and pathology with the correct combination of medications. To change the long term characteristics of the dysfunctional personality. To reduce the inflexibility of personality traits that interfere with functioning and relationships. A client has been prescribed sertraline (Zoloft) for one week. One day after the dose of this medication is increased to 150mg. the client begins to present with confusion, restlessness and tremors as well as muscle rigidity and temperature of 39.4 C (1029 F). The nurse assesses that these symptoms are most likely associated with which condition? Agranulocytosis Serotonin Syndrome Hypertensive Crisis Neuroleptic Malignant Syndrome The nurse is working in the outpatient clinic with a client with a long history of alcohol abuse. The client has been drinking 9 beers almost every day but is motivated to redue drinking. In addition to encouraging the client to attend support groups in the community, which medication would the nurse recognize as appropriate when prescribed for tI individual? Disulfiram (Antabuse) Clonazepam (Klonopin) Naltrexone (Revia) Acamprosate(Campral) The nurse suspects that a client admitted to the medical floor may have a drinking problem. How should the nurse further assess this possibility? By completing the AIMS assessment with the client. By reviewing the client’s most recent lab values. By using a screening tool such as the CAGE questionnaire. By thoroughly assessing the client using the CIWA scale. In shift report, the off-going nurse states “The client has been experiencing an increase in positive symptoms of schizophrenia.” Which symptoms would the nurse expect to observe in the client? Select all that apply. Hallucinations Social withdrawal and isolation Flat affect Bizarre and disorganized conversation Delusional thought content A client has taken lithium and risperidone (Risperdal) daily for 2 weeks. The client now complains of loose stools, upset stomach, vomiting, and change in eyesight. The nurse observes a coarse hand tremor and slurred speech. What nursing action is high priority? Hold the next dose of lithium and order a stat lithium level. Give the client lorazepam to relieve extrapyramidal symptoms. Reassure the client that the symptoms being experienced will decrease with time. Hold the next dose of risperidone to prevent further drug-drug interaction. The nurse is educating a student who is working with a client diagnosed with schizophrenia about symptoms associated with less favorable outcomes. Which statement by the student indicates an understanding of the teaching provided? “There are less favorable outcomes for clients who report that the TV is sending them messages.” “Clients with more negative symptoms such as flat affect and social withdrawal have the best outcomes and respond well to medications such as fluphenazine (Prolixin).” “Clients who hear distressing voices continuously have less favorable outcomes.” “Individuals with little or no interest in work or social activities have less favorable outcomes. A client diagnosed with a personality disorder comes to the nurses’ station at 2300 requesting a phone call to a lawyer to discuss filing for a divorce. The unit policy states that no phone calls are permitted after 2200. What is the most therapeutic response by the nurse? “The decision to divorce can wait until after you are out of the hospital” “I will make an exception for tonight. But please respect the 10 p.m. phone call policy.” “You know the rules about phone calls after 10:00 p.m. What is really going on?” “It is after the 10:00 p.m. limit for phone calls. You will be able to call tomorrow.” A client with a diagnosis of schizophrenia approaches the nurse and states, “The devil is talking to me.Which response by the nurse is most therapeutic? “I don’t hear the voices but I can see that you are upset right now” “Do you think you are bad? Why do you think the voices are telling you this?” “You can take your PRN of Olanzapine (Zyprexa) if you are feeling anxious” “Let’s not focus on the voices right now. You can go join the group* A client presents to the ED severely intoxicated with alcohol. The client falls asleep and wakes up after 12 hours and is observed to be diaphoretic and tremulous with Vital signs as follows: T38.8 C (101.8F) HR 132. BP 150/90. R 20. Which assessment would be the priority for the nurse to ensure the client’s safety? CAGE CIWA AIMS AUDIT A client experiencing psychosis with significant paranoia screams at the nurse when approached with medication, “Why are you trying to poison me. This is the wrong pill. It’s WRONG” Which nursing action is most appropriate? Hold the medication and inform the provider of the client’s refusal. Double-check the medication and the order to ensure that the medication is correct. Inform the client that an injection will be given if the pill is not taken. Reassure the client that the medication has been prescribed and is safe to take. The nurse plans to measure orthostatic blood pressure in a client taking quetiapine (Seroquel). Which statement is correctly describing the steps of assessing the orthostatic blood pressure? Select all that apply. Have the client sit for 1-2 minutes. Have the client lie down for 5 minutes. A drop in systolic BP of ≥20 mmHg, or in diastolic BP of ≥ 10 mmHg is orthostatic hypotension. Have the client stand for 1-3 minutes. Subjective experiences of lightheadedness or dizziness is NOT considered as having orthostatic hypotension. A nurse would be most likely to complete the Abnormal Involuntary Movement scale (AIMS) for a client taking which medication? Fluphenazine (Prolixin) Paroxetine (Paxil) Valproic Acid (Depakote) Lorazepam (Ativan) Which client would the nurse assess as being at highest risk for a life threatening hypertensive crisis? A client who is prescribed buspirone (Buspar) and takes prazosin (Minipress) to help with nightmares. A client who is prescribed nortriptyline (Pamelor) and drinks coffee. A client prescribed diazepam (Valium) and goes out for drinks with friends. A client who is prescribed tranylcypromine (Parnate) and takes Robitussin for a cold. The nurse is interviewing a client who was admitted the previous night after an overdose of sleeping pills. The client states. “Please don’t tell anyone I was raped last month. No one can know about this. Which response by the nurse is most appropriate? “Why do you want to keep this a secret? You do not need to be ashamed of this.” “I need to share this information with the whole treatment team to appropriately plan your care.” “Let’s talk more about the rape. Can you tell me more details about what happened?” “Thank you for trusting me. Yes, I will keep this information confidential!” A client is prescribed chlorpromazine (Thorazine) for auditory hallucinations and delusions associated with a diagnosis of schizophrenia. The nurse suspects that the client is developing Neuroleptic Malignant Syndrome. Which symptoms assess a risk for Neuroleptic Malignant Syndrome (NMS)? Select all that apply. Autonomic instability with HR 140 Temperature 103 degrees F Ongoing delusions and hallucinations Tremor Lead-pipe rigidity in all muscle groups Which intervention would be most appropriate when planning care for a client exhibiting negative symptoms of schizophrenia? Allow the client to stay in bed and rest. Encourage the client to socialize with other clients at mealtime. Accompany the client to short activities in the milieu. Tell the client that group participation is required for discharge. The nurse is working with a client who refuses to eat and states, “I know they have gotten to the food here and it is poisoned.” Which nursing intervention is most appropriate? Distract the client at mealtime by sitting and engaging in conversation. Offer to eat a bite of food from the client’s tray at each meal. Suggest the provider re-evaluate the client’s current medication regime. Provide food in sealed containers which the client can open. The nurse is evaluating if a client’s delusions are decreasing. Which best indicates that the client is still experiencing delusions? Select all that apply. The client looks at the window and listens, laughs, and then nods in agreement. The client sits in the same spot every day in the day room and does not talk to others or participate in activities. The client states, “I am Harry Potter. Can you please call me Harry? I need to get back to Hogwarts.” The client reports receiving personal messages from the TV and the radio. The client states, “I am the king and this is my kingdom! I can do whatever I want!” A client is brought to the ED by police after yelling at individuals on the street outside of Harborview. The client was stating, “I will kill you. I don’t care if I get arrested. I am going to kill myself anyway.” The client has a malnourished appearance and declines food and fluid in the ED stating, “I know you are trying to poison me.” The nurse recognizes which reasons to initiate a referral for involuntary treatment for this client? Select all that apply. The client is a danger to self. The client is disruptive to the community. The client is a danger to others. The client is not adherent with prescribed medications. The client is gravely disabled and not able to meet basic needs. The nurse has received shift report and is now starting client assessments. Which client is the priority to assess first? A client with schizophrenia who is loudly responding to internal stimuli in the day room. A client who is detoxing from alcohol and on CIWA. Last CIWA was one hour prior and the client did not require medication. The client with borderline personality disorder who had a suicide attempt the prior evening who refuses to engage in safety planning. A voluntarily admitted client who is refusing AM medication and is demanding to be discharged. The nurse educates a client with a 10-year of alcohol use disorder that the rationale for giving thiamine (B1) and a multivitamin to the client is to reduce the risk of Wernicke’s encephalopathy. True False A client with Borderline Personality Disorder has been attending an outpatient Dialectical Behavior Therapy program. Which outcome would indicate that the treatment has been effective? The client participates in role plays to practice responses in social situations. The client is able to tolerless-than-perfectfect grades. When the client gets a “B” on an exam, the client states. “I still enjoyed the class.” The client engages in more social relationships and reports feeling less anxious around others. The client remains free from self-harm and identifies two other coping skills to manage painful feelings. A client with generalized anxiety disorder is prescribed lorazepam (Ativan) and buspirone (Buspar). Which client statement indicates that the teaching by the nurse has been effective? “Ativan is the treatment of choice for long term management of anxiety.” “I will take the Ativan for a short time until the Buspar starts to work. “Buspar can get me addicted so I will only take it for a couple of weeks.” “The Buspar will start to work right away to manage my anxiety.” Which information suggests that caution is necessary in prescribing diazepam (Valium) to a client with anxiety? The client has a history of alcohol dependence. The client has a history of a seizure disorder. The client has a history of hypertension. The client has a history of sleep disorders. The nurse is assessing a client who is prescribed Olanzapine (Zyprexa). The client experienced significant weight gain of 20 pounds over a 3 month period and now has a BMI of 35. What other indicators would the nurse review to evaluate the client for metabolic syndrome? Select all that apply. Hemoglobin A1C Kidney Function Tests Waist Circumference Blood Pressure Fasting Lipids A client with a long history of alcohol abuse and dependence is prescribed Disulfiram (Antabuse). The nurse has completed the teaching about this medication. Which client statement indicates that the teaching has been effective? “If I plan to have a drink, I will stop my Antabuse the night before so I don’t have a reaction.” “Only large quantities of alcohol will cause a reaction so a drink once in a while is ok.” “As long as I don’t drink alcohol, there are no other precautions needed.” “I will need to check labels of all products and avoid any items that contain alcohol.” A client with a long history of alcohol abuse and dependence is prescribed Disulfiram (Antabuse). The nurse has completed the teaching about this medication. Which client statement indicates that the teaching has been effective? “If I plan to have a drink. I will stop my Antabuse the night before so I don’t have a reaction” “Only large quantities of alcohol will cause a reaction so a drink once in a while is ok.” “As long as I don’t drink alcohol, there are no other precautions needed” “I will need to check labels of all products and avoid any items that contain alcohol.” A client calls the outpatient clinic after starting on Lamotrigine (Lamictal) three days ago. The client reports developing a rash overnight and asks the nurse about stopping the medication. Which response by the nurse is most appropriate? “Have you had rashes before when you start on new medications? Just continue the medication and see if it resolves. Call back if it gets worse.” “Tell me more about the rash. I don’t think it is anything to worry about but I can schedule you for an appointment later this week.” “This is an expected reaction with this medication. If the rash gets worse, call back and we will schedule an appointment with your provider” “Stop the medication and I will contact your provider. We will get you in for an appointment today.” A client calls the outpatient clinic after starting on Lamotrigine (Lamictal) three days ago. The client reports developing a rash overnight and asks the nurse about stopping the medication. Which response by the nurse is most appropriate? “Have you had rashes before when you start on new medications? Just continue the medication and see if it resolves. Call back if it gets worse.” “Tell me more about the rash. I don’t think it is anything to worry about but I can schedule you for an appointment later this week.” “This is an expected reaction with this medication. If the rash gets worse, call back and we will schedule an appointment with your provider.” “Stop the medication and I will contact your provider. We will get you in for an appointment today.” A client is prescribed clomipramine (Anafranil). Which side effects would the nurse assess for with this medication? Polyuria and course hand tremors Excessive salivation and dysuria Orthostatic hypotension and constipation Unusual bleeding and bruising A client who started taking thiothixene (Navane) two days ago reports feeling jittery and restless. The client states, “I just can’t sit still” Which assessment by the nurse is most likely based upon the client’s presentation? The client is having an acute dystonic reaction. The client is experiencing akathisia The client is developing tardive dyskinesia. The client is experiencing anxiety related to starting a new medication.

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