Question 1

A nurse is assessing a client diagnosed with schizophrenia.The nurse asks the client,"Do you receive special messages from certain sources,such as the television or radio?" Which potential symptom of this disorder is the nurse assessing?

Accepted Answer

The nurse is assessing for the potential symptom of delusions of reference.A client who believes that he or she receives messages through the radio is experiencing delusions of reference.When a client experiences these delusions,he or she interprets all events within the environment as personal references.

Question 2

Which nursing intervention would be most appropriate when caring for an acutely agitated client with paranoia?

Accepted Answer

The most appropriate nursing intervention is to provide personal space to respect the client's boundaries.Providing personal space may serve to reduce anxiety and thus reduce the client's risk for violence.

Question 3

A client diagnosed with schizophrenia states,"Can't you hear him? It's the devil.He's telling me I'm going to hell." Which is the most appropriate nursing reply?

Accepted Answer

The most appropriate reply by the nurse is to reassure the client with an accepting attitude while not reinforcing the hallucination.

Question 4

Parents ask a nurse how they should reply when their child,diagnosed with schizophrenia,tells them that voices command him to harm others.Which is the appropriate nursing reply?

Accepted Answer

The most appropriate response by the nurse is to instruct the parents to focus on the feelings generated by the hallucinations and present reality.The parents should maintain an attitude of acceptance to encourage communication but should not reinforce the hallucinations by exploring details of content.It is inappropriate to present logical arguments to persuade the client to accept the hallucinations as not real.

Question 5

Which statement should indicate to a nurse that an individual is experiencing a delusion?

Accepted Answer

The nurse should recognize that a client who claims that an alien is inside his or her body is experiencing a delusion.Delusions are false personal beliefs that are inconsistent with the person's intelligence or cultural background.

Question 6

A client who is admitted to the inpatient psychiatric unit and is taking Thorazine presents to the nurse with severe muscle rigidity,tachycardia,and a temperature of 105°F (40.5°C).The nurse identifies these symptoms as which of the following conditions?

Accepted Answer

Neuroleptic malignant syndrome is a potentially fatal condition characterized by muscle rigidity,fever,altered consciousness,and autonomic instability.

Question 7

An elderly client diagnosed with schizophrenia takes an antipsychotic and a beta-adrenergic blocking agent (propranolol)for hypertension.Understanding the combined side effects of these drugs,the nurse would most appropriately make which statement?

Accepted Answer

The most appropriate statement by the nurse is to instruct the client to rise slowly when changing positions.Antipsychotic medications and beta blockers cause a decrease in blood pressure.When given in combination,this side effect places the client at risk for developing orthostatic hypotension.

Question 8

During an admission assessment,a nurse asks a client diagnosed with schizophrenia,"Have you ever felt that certain objects or persons have control over your behavior?" The nurse is assessing for which type of thought disruption?

Accepted Answer

The nurse is assessing the client for delusions of influence when asking if the client has ever felt that objects or persons have control of the client's behavior.Delusions of control or influence are manifested when the client believes that his or her behavior is being influenced.An example would be if a client believes that a hearing aid receives transmissions that control personal thoughts and behaviors.

Question 9

A client diagnosed with schizoaffective disorder is admitted for social skills training.Which information should be taught by the nurse?

Accepted Answer

The nurse should plan to teach the client how to make eye contact when communicating.Social skills,such as making eye contact,can assist clients in communicating needs and maintaining connectedness.

Question 10

A client is diagnosed with schizophrenia.A physician orders haloperidol (Haldol),50 mg bid; benztropine (Cogentin),1 mg prn; and zolpidem (Ambien),10 mg HS.Which client behavior would warrant the nurse to administer benztropine?

Accepted Answer

The symptom of tactile hallucinations and reports of hearing disturbing voices would be addressed by an antipsychotic medication such as haloperidol.Tardive dyskinesia,a potentially irreversible condition,would warrant the discontinuation of an antipsychotic medication such as haloperidol.An anticholinergic medication such as benztropine would be used to treat the extrapyramidal symptoms of restlessness and muscle rigidity.

Question 11

A client diagnosed with schizophrenia tells a nurse,"The 'Shopatouliens' took my shoes out of my room last night." Which is an appropriate charting entry to describe this client's statement?

Accepted Answer

The nurse should describe the client's statement as experiencing a neologism.A neologism is when a client invents a new word that is meaningless to others but may have symbolic meaning to the client.Word salad refers to a group of words that are put together randomly.

Question 12

A client diagnosed with schizophrenia,who has been taking antipsychotic medication for the last 5 months,presents in an emergency department (ED)with uncontrollable tongue movements,stiff neck,and difficulty swallowing.The nurse would expect the physician to recognize which condition and implement which treatment?

Accepted Answer

The nurse should expect that an ED physician would diagnose the client with tardive dyskinesia and discontinue antipsychotic medications.Tardive dyskinesia is a condition of abnormal involuntary movements of the mouth,tongue,trunk,and extremities that can be an irreversible side effect of typical antipsychotic medications.

Question 13

A 16-year-old client diagnosed with schizophrenia experiences command hallucinations to harm others.The client's parents ask a nurse,"Where do the voices come from?" Which is the appropriate nursing reply?

Accepted Answer

The nurse should explain that a chemical imbalance of the brain leads to altered thought processes.Hallucinations,or false sensory perceptions,may occur in all five senses.The client who hears voices is experiencing an auditory hallucination.

Question 14

Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia?

Accepted Answer

The nurse can enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia by being reliable,honest,and consistent during interactions.The nurse should also convey acceptance of the client's needs and maintain a calm attitude when dealing with agitated behavior.

Question 15

A paranoid client presents with bizarre behaviors,neologisms,and thought insertion.Which nursing action should be prioritized to maintain this client's safety?

Accepted Answer

The nurse should note escalating behaviors and intervene immediately to maintain this client's safety.Early intervention may prevent an aggressive response and keep the client and others safe.

Question 16

A nurse is caring for a client who is experiencing a flat affect,paranoia,anhedonia,anergia,neologisms,and echolalia.Which statement correctly differentiates the client's positive and negative symptoms of schizophrenia?

Accepted Answer

The nurse should recognize that positive symptoms of schizophrenia include paranoid delusions,neologisms,and echolalia.The negative symptoms of schizophrenia include flat affect,anhedonia,and anergia.Positive symptoms reflect an excess or distortion of normal functions.Negative symptoms reflect a decrease or loss of normal functions.

Question 17

A client diagnosed with schizophrenia is slow to respond and appears to be listening to unseen others.Which medication should a nurse expect a physician to order to address this type of symptom?

Accepted Answer

The nurse should expect the physician to order risperidone (Risperdal)to address the positive symptoms of schizophrenia.Risperidone (Risperdal)is an atypical antipsychotic used to reduce positive symptoms,including disturbances in content of thought (delusions),form of thought (neologisms),or sensory perception (hallucinations).

Question 18

A client diagnosed with brief psychotic disorder tells a nurse about voices telling him to kill the president.Which nursing diagnosis should the nurse prioritize for this client?

Accepted Answer

The nurse should prioritize the diagnosis risk for violence: directed toward others.A client who hears voices telling him to kill someone is at risk for responding and reacting to the command hallucination.Other risk factors for violence include aggressive body language,verbal aggression,catatonic excitement,and rage reactions.

Question 19

A client diagnosed with schizophrenia takes an antipsychotic agent daily.Which assessment finding should a nurse immediately report to the client's attending psychiatrist?

Accepted Answer

When assessing a client diagnosed with schizophrenia who takes an antipsychotic agent daily,the nurse should immediately address a temperature of 104°F (40°C).A temperature this high can be a symptom of the rare but life-threatening neuroleptic malignant syndrome.

Question 20

A client diagnosed with schizophrenia states,"My psychiatrist is out to get me.I'm sad that the voice is telling me to stop him." What symptom is the client exhibiting,and what is the nurse's legal responsibility related to this symptom?

Accepted Answer

The nurse should determine that the client is exhibiting command hallucinations.The nurse's legal responsibility is to warn the psychiatrist of the potential for harm.A client who is demonstrating a risk for violence could potentially become physically,emotionally,and/or sexually harmful to others or to self.

Quiz 24: Schizophrenia Spectrum and Other Psychotic Disorders