Correct Answer: A

Rationale: Uncontrolled movements around the mouth. Tardive dyskinesia is a side effect associated with the long-term use of antipsychotic medications, especially first-generation or typical antipsychotics. It is characterized by involuntary, repetitive movements, often involving the face, such as uncontrolled movements around the mouth (e.g., lip smacking, puckering, chewing). Seizures and tremors are not typical adverse effects of tardive dyskinesia. They are more commonly associated with other side effects or conditions. Nausea and vomiting are not typically associated with tardive dyskinesia. These symptoms may be side effects of antipsychotic medications, but they are not characteristic of tardive dyskinesia itself. Hallucinations and delusions are not associated with tardive dyskinesia. Tardive dyskinesia primarily involves involuntary movements and is not related to changes in thought content or perception.

Correct Answer: A,D,E,F,G

Rationale: A. Sodium level: Abnormal sodium levels can have serious consequences, including neurological symptoms. Immediate follow-up is necessary to assess and manage electrolyte imbalances, as severe cases can lead to complications such as seizures. B. Phosphate level: While phosphate levels are important to monitor, they may not require immediate follow-up unless severe abnormalities are present. Severe phosphate imbalances can occur in the context of malnutrition, but they may not necessitate immediate intervention in the ED unless critical. C. Magnesium level: Similar to phosphate, magnesium levels are crucial but may not demand immediate follow-up unless severe abnormalities are detected. While magnesium imbalances can occur in eating disorders, the urgency depends on the extent of the imbalance. D. Respiratory rate: Rapid or abnormal respiratory rates can be indicative of respiratory distress, which may occur in individuals with severe anorexia nervosa. Monitoring and addressing respiratory issues promptly are crucial for the client's respiratory function. E. Capillary refill: Capillary refill is included in the list of findings that require immediate follow-up. Prolonged capillary refill time indicates potential issues with peripheral perfusion and warrants prompt attention to assess and address any circulation concerns. F. Blood pressure: Abnormal blood pressure, especially low blood pressure, can indicate cardiovascular compromise, which is a concern in severe cases of anorexia nervosa. Monitoring and addressing abnormal blood pressure promptly are essential for the client's well-being. G. Glucose level: Anorexia nervosa can lead to hypoglycemia, and low glucose levels can result in various complications, including neurological symptoms. Immediate follow-up is necessary to assess and manage glucose levels for the well-being of the client.

Correct Answer: A

Rationale: Offer the client high-calorie foods that he/she can eat with their hands and fluids frequently. Clients experiencing acute mania often have increased energy levels and may engage in hyperactive behaviors, leading to a high calorie expenditure. Offering high-calorie foods that can be eaten with hands and fluids frequently can help meet the increased energy needs of the client. It's important to ensure proper nutrition and hydration during the manic episode. Playing loud music for the client in her room may exacerbate the heightened arousal and agitation associated with mania. It is important to create a calm and structured environment. Engaging the client in a small group activity may be overwhelming and contribute to increased stimulation. Individual activities or smaller, quieter groups may be more appropriate for a client in acute mania. Instructing the client to avoid napping during the day may not be practical. Clients in acute mania often have reduced need for sleep, and forcing them to avoid napping may increase agitation and restlessness. It's essential to balance rest with activity and monitor for signs of exhaustion.

Correct Answer: A

Rationale: Grandiosity. Grandiosity is a symptom commonly seen in the manic phase of bipolar disorder. It involves an inflated sense of self-importance, unrealistic beliefs in one's abilities, and a perception of being involved in activities that are revolutionary or of great significance. In this scenario, the client's statement about revolutionizing the industry reflects grandiosity. Clang associations involve the association of words based on sound rather than meaning and are often seen in individuals with thought disorders. Flight of ideas refers to a rapid flow of thoughts, often manifested by speech that is difficult to interrupt, with topics changing rapidly. Confabulation is the creation of false or distorted memories without the intention to deceive. It is not a characteristic behavior of mania in bipolar disorder.

Correct Answer: D

Rationale: What happened to you in the past to make you so desperate?' may be seen as judgmental and may not be as helpful in the immediate crisis. It assumes a specific cause for the desperation and might not address the current feelings or circumstances that are contributing to the suicidal thoughts. 'What will you accomplish by taking your life?' This question may be perceived as confrontational or dismissive of the client's feelings. It might not provide a clear understanding of the immediate risk or plan. 'Why do you feel depressed enough to end your life?' is a direct question that may put pressure on the client and might not be as effective in exploring their thoughts and feelings. It assumes a direct link between depression and suicidal thoughts without allowing for a more nuanced exploration. 'How will you carry out your plan?' This question is crucial because it helps assess the seriousness of the client's intent and the immediacy of the risk. Understanding the specifics of the plan can help the nurse evaluate the level of danger and take appropriate actions to ensure the client's safety.