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    Hesi rn psychology proctored exam (mental health)

    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. Assist the client in recognizing her manifestations of anxiety: While education about anxiety is important, the observed involuntary movements are more indicative of a movement disorder such as tardive dyskinesia rather than anxiety. Addressing anxiety would not capture the clinical significance of the symptom. B. Prepare to initiate seizure precautions for the client's safety: Involuntary foot tapping while seated does not indicate seizure activity. Seizure precautions are unnecessary unless other signs, such as loss of consciousness or tonic-clonic movements, are present. C. Advise the client that she has developed tolerance to the medication: Tolerance refers to reduced therapeutic effect over time, not the emergence of involuntary movements. Involuntary movements are an adverse effect of long-term antipsychotic use and should not be misattributed to tolerance. D. Document the finding on the Abnormal Involuntary Movement Scale: Using the Abnormal Involuntary Movement Scale (AIMS) provides a standardized way to assess and monitor extrapyramidal symptoms, including tardive dyskinesia. Documenting the observation ensures accurate reporting, tracks progression, and informs the healthcare provider’s decision regarding medication management.

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