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    RN HESI Mental Health with NGN Proctored Exam

    When assessing a female client who has been taking an antipsychotic medication for the past year, the nurse observes that the client demonstrates involuntary foot tapping while both feet are flat on the floor. The nurse plans to report the observation to the healthcare provider. Which additional action should the nurse take?

    Explanation & Rationale

    Choice A rationale: Documenting the finding on the Abnormal Involuntary Movement Scale (AIMS) is appropriate. The AIMS is a standardized tool used to assess and document abnormal movements associated with antipsychotic medications, such as tardive dyskinesia. Choice B rationale: Assisting the client in recognizing her manifestations of anxiety is unrelated to the observed foot tapping and does not address the potential side effects of antipsychotic medication. Choice C rationale: Preparing to initiate seizure precautions for the client's safety is not indicated based on the observed foot tapping. Seizure precautions are not typically associated with antipsychotic medication side effects. Choice D rationale: Advising the client that she has developed tolerance to the medication is speculative and not supported by the information provided. The observed foot tapping may be indicative of extrapyramidal side effects rather than tolerance.

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