NursingPlex
    Sign In
    Rn Hesi Mental Health Proctored Exam 1

    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

    A) Involuntary foot tapping may be indicative of tardive dyskinesia, a potentially serious side effect of long-term antipsychotic medication use. Documenting the finding on the Abnormal Involuntary Movement Scale allows for systematic assessment and monitoring of movement disorders. B) While anxiety manifestations should be addressed, foot tapping in this context is more likely related to medication side effects rather than anxiety. C) There is no indication that the foot tapping is related to seizures, so initiating seizure precautions would not be appropriate. D) Advising the client about tolerance to the medication is not indicated in this situation, as the observed foot tapping is more suggestive of a movement disorder side effect rather than tolerance.

    🔒 Submit your answer to reveal