一位患有精神分裂症並服用 Haloperidol 三年的個案，護理師觀察到其有反覆舌頭運動及舔唇動作。護理師應採取何種行動？
A client with schizophrenia has been on haloperidol for three years. The nurse observes the client making repetitive tongue movements and lip-smacking. Which action should the nurse take?
- ADocument the findings and notify the healthcare provider✓ 正解記錄發現並通知醫療提供者
- BAssess the client for signs of acute dystonia評估病人是否有急性肌張力不全的徵象
- CIncrease the frequency of physical activity增加身體活動頻率
- DAdminister the next dose of medication as scheduled按時給予下一劑藥物
個案出現的舌頭與唇部反覆運動為遲發性運動障礙（Tardive Dyskinesia, TD）的典型臨床表現，屬於長期服用抗精神病藥物的嚴重副作用。護理師應準確記錄異常動作並通知醫師，以便評估是否需要調整藥物或停用，這類狀況若不及早處理可能成為永久性傷害。
The repetitive tongue and lip movements observed in this client are classic manifestations of tardive dyskinesia (TD), a serious adverse effect of long-term antipsychotic therapy. The nurse should accurately document the abnormal movements and notify the provider, so that the medication can be evaluated for adjustment or discontinuation. If not addressed early, this condition may become permanent.
美國護理師常使用 AIMS 量表評估 TD，台灣臨床護理評估相對較少使用標準量表。