Question 1

Parents ask a nurse how they should reply when their child, diagnosed with paranoid schizophrenia, tells them that voices command him to harm others. Which is the appropriate nursing reply?&#10;A)&#34;Tell him to stop discussing the voices.&#34;&#10;B)&#34;Ignore what he is saying, while attempting to discover the underlying cause.&#34;&#10;C)&#34;Focus on the feelings generated by the hallucinations and present reality.&#34;&#10;D)&#34;Present objective evidence that the voices are not real.&#34;

Accepted Answer

The appropriate nursing response is to focus on the feelings generated by the hallucinations and present reality. It is important to acknowledge the child's experience, but also ground them in reality by providing a safe and supportive environment that fosters a sense of control and understanding of their mental illness. Trying to ignore or dismiss what the child is saying may cause them to feel invalidated and escalate their distress. Trying to present objective evidence of something that the child perceives as real may not be effective and potentially harmful.

Question 2

After taking chlorpromazine (Thorazine) for 1 month, a client presents to an emergency department (ED) with severe muscle rigidity, tachycardia, and a temperature of 105^oF (40.5^$\circ$C). The nurse expects the physician to recognize which condition and implement which treatment?

A)Neuroleptic malignant syndrome and treat by discontinuing Thorazine and administering dantrolene (Dantrium)
B)Neuroleptic malignant syndrome and treat by increasing Thorazine dosage and administering an antianxiety medication
C)Dystonia and treat by administering trihexyphenidyl (Artane)
D)Dystonia and treat by administering bromocriptine (Parlodel)

Neuroleptic malignant syndrome and treat by discontinuing Thorazine and administering dantrolene (Dantrium)

Accepted Answer

The client is exhibiting symptoms of neuroleptic malignant syndrome, a potentially life-threatening reaction to antipsychotic medications like Thorazine. The treatment involves immediately discontinuing the Thorazine and administering dantrolene to help reduce muscle rigidity and fever. Option B is incorrect because increasing the dosage of Thorazine can worsen symptoms, while an antianxiety medication may not be effective in treating neuroleptic malignant syndrome. Options C and D are also incorrect as dystonia is a different condition than neuroleptic malignant syndrome and requires different treatments.

Question 3

Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia?&#10;A)Establishing personal contact with family members.&#10;B)Being reliable, honest, and consistent during interactions.&#10;C)Sharing limited personal information.&#10;D)Sitting close to the client to establish rapport.

Accepted Answer

Being reliable, honest, and consistent during interactions is crucial to building trust with a client diagnosed with schizophrenia. This population often struggles with paranoia and may be hesitant to trust others. By consistently being reliable and honest, the nurse can show the client that they are dependable and can be trusted. Establishing personal contact with family members may also be helpful in establishing trust, but it is not the best choice compared to being reliable and consistent during interactions. Sharing limited personal information and sitting close to the client may not be appropriate or effective strategies for building trust with clients diagnosed with schizophrenia.

Question 4

A client diagnosed with psychosis NOS (not otherwise specified) tells a nurse about voices telling him to kill the president. Which nursing diagnosis should the nurse prioritize for this client?&#10;A)Disturbed sensory perception&#10;B)Altered thought processes&#10;C)Risk for violence: directed toward others&#10;D)Risk for injury

Accepted Answer

The client's statement about hearing voices instructing him to kill the president indicates a risk for violence directed toward others. This is the priority nursing diagnosis and requires immediate intervention to ensure the safety of the client and others. Disturbed sensory perception and altered thought processes may also apply, but do not take priority over the risk for violence. Risk for injury is a broad diagnosis without specific information related to the client's actual or potential harm.

Question 5

An aging client diagnosed with chronic schizophrenia takes an antipsychotic and a beta-adrenergic blocking agent (propranolol) for hypertension. Understanding the combined side effects of these drugs, which statement by a nurse is most appropriate?

A)"Make sure you concentrate on taking slow, deep, cleansing breaths."
B)"Watch your diet and try to engage in some regular physical activity."
C)"Rise slowly when you change position from lying to sitting or sitting to standing."
D)"Wear sunscreen and try to avoid midday sun exposure."

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Accepted Answer

The combination of an antipsychotic medication and a beta-adrenergic blocking agent can cause orthostatic hypotension, which is a sudden drop in blood pressure when changing position from lying to sitting or sitting to standing. The nurse should advise the client to rise slowly when changing position to avoid falls or fainting. The other options are not directly related to the side effects of these medications.

Question 6

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?

A)Delusions of persecution
B)Delusions of influence
C)Delusions of reference
D)Delusions of grandeur

Accepted Answer

Delusions of influence involve the belief that an outside force or person is controlling one's thoughts or actions. This question is specifically asking if the client has ever felt that objects or persons have control over their behavior, which aligns with delusions of influence. Delusions of persecution involve the belief that someone or something is out to harm the individual, delusions of reference involve the belief that external events or objects have special meaning for the individual, and delusions of grandeur involve the belief that the individual has special abilities or powers.

Question 7

Which statement should indicate to a nurse that an individual is experiencing a delusion?&#10;A)&#34;There's an alien growing in my liver.&#34;&#10;B)&#34;I see my dead husband everywhere I go.&#34;&#10;C)&#34;The IRS may audit my taxes.&#34;&#10;D)&#34;I'm not going to eat my food.It smells like brimstone.&#34;

Accepted Answer

A delusion is a false belief that is firmly held and not based in reality. Option A, "There's an alien growing in my liver," is a statement that is not based in reality and indicates a delusion. Option B could indicate a hallucination or grief response, but not necessarily a delusion. Option C is a realistic concern, and option D could indicate a sensory perception issue such as smelling something that is not there.

Question 8

A client diagnosed with paranoid 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?

A)Magical thinking; administer an antipsychotic medication
B)Persecutory delusions; orient the client to reality
C)Command hallucinations; warn the psychiatrist
D)Altered thought processes; call an emergency treatment team meeting

Accepted Answer

The client is exhibiting command hallucinations, which involves hearing voices telling them to do something. It is the nurse's legal responsibility to warn the psychiatrist about the potential danger. This is important to ensure the safety of both the client and the psychiatrist.

Question 9

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

A)Paranoid delusions, anhedonia, and anergia are positive symptoms of schizophrenia.
B)Paranoid delusions, neologisms, and echolalia are positive symptoms of schizophrenia.
C)Paranoid delusions, anergia, and echolalia are negative symptoms of schizophrenia.
D)Paranoid delusions, flat affect, and anhedonia are negative symptoms of schizophrenia.

Accepted Answer

Positive symptoms of schizophrenia are behaviors or thoughts that are present that should not be, such as hallucinations, delusions, neologisms (invented words), and echolalia (repeating words or phrases). Negative symptoms of schizophrenia are behaviors or thoughts that are absent that should be present, such as flat affect (lack of emotional expression), anhedonia (lack of enjoyment in activities), and anergia (lack of energy). Therefore, the correct answer is B as the three symptoms listed (paranoid delusions, neologisms, and echolalia) are positive symptoms, while the other four are negative symptoms.

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?

A)Tactile hallucinations
B)Tardive dyskinesia
C)Restlessness and muscle rigidity
D)Reports of hearing disturbing voices

Accepted Answer

Restlessness and muscle rigidity are symptoms of extrapyramidal side effects (EPS), which can occur with the use of haloperidol. Benztropine is used to treat these symptoms. Tactile hallucinations and hearing disturbing voices are symptoms of psychosis, which haloperidol is being used to treat. Tardive dyskinesia is a potential long-term side effect of antipsychotic medication, including haloperidol, but benztropine would not be used to treat it. Zolpidem is a sleep aid and not relevant to this situation.

Question 11

A client diagnosed with schizophrenia states, &#34;Can't you hear him? It's the devil. He's telling me I'm going to hell.&#34; Which is the most appropriate nursing reply?&#10;A)&#34;Did you take your medicine this morning?&#34;&#10;B)&#34;You are not going to hell.You are a good person.&#34;&#10;C)&#34;I'm sure the voices sound scary.The devil is not talking to you.This is part of your illness.&#34;&#10;D)&#34;The devil only talks to people who are receptive to his influence.&#34;

Accepted Answer

The answer of A client diagnosed with schizophrenia states, &#34;Can't...

Question 12

A 16-year-old-client diagnosed with paranoid 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?

A)"Your child has a chemical imbalance of the brain which leads to altered thoughts."
B)"Your child's hallucinations are caused by medication interactions."
C)"Your child has too little serotonin in the brain causing delusions and hallucinations."
D)"Your child's abnormal hormonal changes have precipitated auditory hallucinations."

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Accepted Answer

The answer of A 16-year-old-client diagnosed with paranoid schizophrenia experiences...

Question 13

A client diagnosed with schizophrenia takes an antipsychotic agent daily. Which assessment finding should a nurse immediately report to the client's attending psychiatrist?&#10;A)Respirations of 22 beats/minute&#10;B)Weight gain of 8 pounds in 2 months&#10;C)Temperature of 104 $\circ$ F (40 $\circ$ C)&#10;D)Excessive salivation

Accepted Answer

The answer of A client diagnosed with schizophrenia takes an...

Question 14

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?&#10;A)Haloperidol (Haldol) to address the negative symptom&#10;B)Clonazepam (Klonopin) to address the positive symptom&#10;C)Risperidone (Risperdal) to address the positive symptom&#10;D)Clozapine (Clozaril) to address the negative symptom

Accepted Answer

The answer of A client diagnosed with schizophrenia is slow...

Question 15

A nurse is assessing a client diagnosed with paranoid 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?

A)Thought insertion
B)Paranoid delusions
C)Magical thinking
D)Delusions of reference

Accepted Answer

The answer of A nurse is assessing a client diagnosed...

Question 16

A client diagnosed with schizophrenia tells a nurse, &#34;The 'Shopatouliens' took my shoes out of my room last night.&#34; Which is an appropriate charting entry to describe this client's statement?&#10;A)&#34;The client is experiencing command hallucinations.&#34;&#10;B)&#34;The client is expressing a neologism.&#34;&#10;C)&#34;The client is experiencing a paranoid delusion.&#34;&#10;D)&#34;The client is verbalizing a word salad.&#34;

Accepted Answer

The answer of A client diagnosed with schizophrenia tells a...

Question 17

A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client's safety?&#10;A)Assess for medication noncompliance&#10;B)Note escalating behaviors and intervene immediately&#10;C)Interpret attempts at communication&#10;D)Assess triggers for bizarre, inappropriate behaviors

Accepted Answer

The answer of A paranoid client presents with bizarre behaviors,...

Question 18

Which nursing intervention would be most appropriate when caring for an acutely agitated client diagnosed with paranoid schizophrenia?&#10;A)Provide neon lights and soft music.&#10;B)Maintain continual eye contact throughout the interview.&#10;C)Use therapeutic touch to increase trust and rapport.&#10;D)Provide personal space to respect the client's boundaries.

Accepted Answer

The answer of Which nursing intervention would be most appropriate...

Question 19

A client diagnosed with chronic schizophrenia 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?

A)Neuroleptic malignant syndrome and treat by discontinuing antipsychotic medications
B)Agranulocytosis and treat by administration of clozapine (Clozaril)
C)Extrapyramidal symptoms and treat by administration of benztropine (Cogentin)
D)Tardive dyskinesia and treat by discontinuing antipsychotic medications

Accepted Answer

The answer of A client diagnosed with chronic schizophrenia presents...

Question 20

A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be taught by the nurse?&#10;A)The side effects of medications&#10;B)Deep breathing techniques to decrease stress&#10;C)How to make eye contact when communicating&#10;D)How to be a leader

Accepted Answer

The answer of A client diagnosed with schizoaffective disorder is...

Question 21

Laboratory results reveal decreased levels of prolactin in a client diagnosed with schizophrenia. When assessing the client, which symptoms should a nurse expect to observe?(Select all that apply.)&#10;A)Apathy&#10;B)Social withdrawal&#10;C)Anhedonia&#10;D)Auditory hallucinations&#10;E)Delusions

Accepted Answer

The answer of Laboratory results reveal decreased levels of prolactin...

Question 22

Which of the following components should a nurse recognize as an integral part of a rehabilitative program when planning care for clients diagnosed with schizophrenia? (Select all that apply.)&#10;A)Group therapy&#10;B)Medication management&#10;C)Deterrent therapy&#10;D)Supportive family therapy&#10;E)Social skills training

Accepted Answer

The answer of Which of the following components should a...

Question 23

A client diagnosed with schizophrenia is prescribed clozapine (Clozaril). Which client symptoms related to the side effects of this medication should prompt a nurse to intervene immediately?&#10;A)Sore throat, fever, and malaise&#10;B)Akathisia and hypersalivation&#10;C)Akinesia and insomnia&#10;D)Dry mouth and urinary retention

Accepted Answer

The answer of A client diagnosed with schizophrenia is prescribed...

Question 24

A nurse is administering risperidone (Risperdal) to a client diagnosed with schizophrenia. The therapeutic effect of this medication would most effectively address which of the following symptoms? (Select all that apply.)

A)Somatic delusions
B)Social isolation
C)Gustatory hallucinations
D)Flat affect
E)Clang associations

Accepted Answer

The answer of A nurse is administering risperidone (Risperdal) to...

Question 25

A college student has quit attending classes, isolates self due to hearing voices, and yells accusations at fellow students. Based on this information, which nursing diagnosis should the nurse prioritize?

A)Altered thought processes R/T hearing voices AEB increased anxiety
B)Risk for other-directed violence R/T yelling accusations
C)Social isolation R/T paranoia AEB absence from classes
D)Risk for self-directed violence R/T depressed mood

Accepted Answer

The answer of A college student has quit attending classes,...

Question 26

A client states, &#34;I hear voices that tell me that I am evil.&#34; Which outcome related to these symptoms should the nurse expect this client to accomplish by discharge?&#10;A)The client will verbalize the reason the voices make derogatory statements.&#10;B)The client will not hear auditory hallucinations.&#10;C)The client will identify events that increase anxiety and illicit hallucinations.&#10;D)The client will positively integrate the voices into the client's personality structure.

Accepted Answer

The answer of A client states, &#34;I hear voices that...

Question 27

If clozapine (Clozaril) therapy is being considered, the nurse should evaluate which laboratory test to establish a baseline for comparison in order to recognize a potentially life-threatening side effect?

A)White blood cell count
B)Liver function studies
C)Creatinine clearance
D)Blood urea nitrogen

Accepted Answer

The answer of If clozapine (Clozaril) therapy is being considered,...

Question 28

A newly admitted client has taken thioridazine (Mellaril) for 2 years with good symptom control. Symptoms exhibited on admission included paranoid delusions and hallucinations. The nurse should recognize which potential cause for the return of these symptoms?

A)The client has developed tolerance to the antipsychotic medication.
B)The client has not taken the medication with food.
C)The client has not taken the medication as prescribed.
D)The client has combined alcohol with the medication.

Accepted Answer

The answer of A newly admitted client has taken thioridazine...

Question 29

A client has been recently admitted to an inpatient psychiatric unit. Which intervention should the nurse plan to use to reduce the client's focus on delusional thinking?&#10;A)Present evidence that supports the reality of the situation&#10;B)Focus on feelings suggested by the delusion&#10;C)Address the delusion with logical explanations&#10;D)Explore reasons why the client has the delusion

Accepted Answer

The answer of A client has been recently admitted to...

Question 30

During an admission assessment, a nurse notes that a client diagnosed with schizophrenia has allergies to penicillin, prochlorperazine (Compazine), and bee stings. Based on this assessment data, which antipsychotic medication would be contraindicated?

A)Haloperidol (Haldol), because it is used only in elderly patients
B)Clozapine (Clozaril), because of a cross-sensitivity to penicillin
C)Risperidone (Risperdal), because it exacerbates symptoms of depression
D)Thioridazine (Mellaril), because of cross-sensitivity among phenothiazines

Accepted Answer

The answer of During an admission assessment, a nurse notes...

Deck 26: Schizophrenia and Other Psychotic Disorders