Question 1

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

Accepted Answer

The term "Shopatouliens" is a made-up word or a neologism, which is a common symptom in schizophrenia where individuals create new words that have meaning only to them.

Question 2

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,which statement by the nurse is most appropriate?

Accepted Answer

The combined side effects of antipsychotic and beta-adrenergic blocking agents include dizziness, lightheadedness, and orthostatic hypotension. Therefore, it is important for the client to rise slowly when changing positions to prevent falls and injury. Options A and B are important for overall health and well-being but do not directly relate to the side effects of these medications. Option D is also important for sun protection but is not directly related to the side effects of these medications.

Question 3

A paranoid client presents with bizarre behaviors,neologisms,and thought insertion.Which is the priority nursing action to maintain this client's safety?

Accepted Answer

The priority nursing action is to note escalating behaviors and intervene immediately to maintain the client's safety. The client's presentation with bizarre behaviors, neologisms, and thought insertion suggests the possibility of psychosis or schizophrenia, which increases the risk of harm to self and others. Therefore, the nurse should closely monitor the client's behavior and intervene promptly to prevent any harm. Assessing medication noncompliance, triggers for bizarre behaviors, and interpreting attempts at communication are also important nursing actions but are not the priority in maintaining the client's immediate safety.

Question 4

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

Accepted Answer

Risperidone is an atypical antipsychotic medication that is often prescribed to address positive symptoms of schizophrenia such as hallucinations and delusions. Haloperidol is also an antipsychotic medication, but it is more commonly used to address the positive symptoms of schizophrenia rather than the negative symptoms. Clonazepam is a benzodiazepine medication that may be used to address anxiety or agitation, but it is not typically used to address hallucinations or delusions in schizophrenia. Clozapine is also an atypical antipsychotic medication that may be used to address both positive and negative symptoms of schizophrenia, but it is generally reserved for treatment-resistant cases due to potential side effects.

Question 5

Which statement indicates to the nurse that a client is experiencing a delusion?

Accepted Answer

A delusion is a false belief that is firmly held despite evidence to the contrary. The statement "There's an alien growing in my liver" is a delusion because it is a false belief that is not based in reality. The other statements may be indicative of other mental health issues (such as grief, anxiety, or paranoia), but they do not necessarily meet the criteria for a delusion.

Question 6

The 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 is the nurse assessing?

Accepted Answer

The question is assessing the symptom of delusions of reference, which involves believing that everyday events or objects have a special and personal meaning intended for the individual. The question specifically asks if the client receives special messages from certain sources such as the television or radio, which is an example of delusions of reference. Thought insertion involves the belief that one's thoughts are being controlled or implanted by an outside force. Paranoia involves excessive mistrust and suspicion of others. Magical thinking involves belief in supernatural or improbable events.

Question 7

The 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

Positive symptoms of schizophrenia include delusions, hallucinations, disordered thinking and speech, neologisms (made-up words), and echolalia (repeating others' words). Negative symptoms include flat affect (lack of emotion), anhedonia (inability to experience pleasure), anergia (lack of energy), and social withdrawal. Paranoia can be considered either a positive or a negative symptom depending on its presentation, but in this case it is listed as a positive symptom. Therefore, choices A, C, and D are incorrect.

Question 8

During an admission assessment,the 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

Delusions of influence refer to the belief that certain objects or persons have control over one's behavior. This type of thought disruption is common in schizophrenia. Delusions of persecution refer to the belief that one is being targeted or persecuted. Delusions of reference refer to the belief that everyday events, objects or behaviors of others have special or personal significance. Delusions of grandeur refer to the belief that one has special powers, talents or abilities.

Question 9

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

Accepted Answer

The client's statement regarding the voices telling him to kill the president indicates a high risk for violence directed towards others. It is important for the nurse to prioritize the safety of the client and those around him. Disturbed sensory perception and altered thought processes may also be present in this situation, but the risk for violence should be prioritized. Risk for injury is too broad and does not address the specific concern of violence towards others.

Question 10

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

Accepted Answer

Being reliable, honest, and consistent during interactions is important in establishing trust with a client diagnosed with Schizophrenia. This population may struggle with trusting others, so it is important for the nurse to consistently demonstrate trustworthiness. Additionally, being reliable and consistent can help to establish routines and expectations that can reduce anxiety and promote a sense of security. Establishing personal contact with family members (A) may be important for developing a comprehensive understanding of the client's support system, but it is not directly related to establishing trust with the client. Sharing limited personal information (C) and sitting close to the client to establish rapport (D) may be appropriate in some circumstances, but these behaviors are not essential for establishing trust with the client.

Question 11

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

Restlessness and muscle rigidity are symptoms of extrapyramidal side effects (EPS) caused by haloperidol. Benztropine is an anticholinergic medication that can help alleviate these symptoms. Tactile hallucinations (A) may be a symptom of schizophrenia, but do not necessarily require the use of benztropine. Tardive dyskinesia (B) is a side effect of long-term use of antipsychotic medication, and benztropine is not typically used to treat it. Zolpidem (Ambien) (C) is a medication used for insomnia and would not be indicated for addressing EPS symptoms.

Question 12

A college student is not attending classes,isolates self because of hearing voices,and yells accusations at fellow students.Based on this information,which should be the nurse's priority nursing diagnosis?

Accepted Answer

The priority nursing diagnosis in this situation is identifying the risk for violence towards others as the student is exhibiting aggressive and accusatory behavior towards fellow students. The student's altered thought processes and social isolation are also concerns, but do not pose an immediate danger to others as the risk for violence does. The risk for self-directed violence is not mentioned in the scenario.

Question 13

Parents ask the 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

Ignoring or telling the child to stop discussing the voices minimizes their experience and may promote feelings of isolation. Presenting objective evidence may also be perceived as an attack on their reality. The appropriate response is to acknowledge the child's experience, but redirect the focus to reality and their feelings. This can help the child manage the hallucinations and reduce distress.

Question 14

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

Accepted Answer

Social skills training focuses on improving communication and interpersonal relationships. Making eye contact is an important aspect of effective communication and can improve social interactions. While medication side effects and stress management techniques may be important to address, they are not directly related to social skills training. Being a leader may also not be a specific focus of social skills training.

Question 15

During an admission assessment,the 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 is contraindicated?

Accepted Answer

Thioridazine belongs to the phenothiazine class of antipsychotic medications, which includes prochlorperazine. Therefore, there is a risk of cross-sensitivity reactions between these medications in people who have allergies to prochlorperazine. Additionally, some studies have suggested that thioridazine may increase the risk of cardiac arrhythmias in people with a history of bee sting allergy. Therefore, thioridazine is contraindicated in this client.

Question 16

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

Accepted Answer

Choice A is the only option that accurately describes the cause of schizophrenia and its symptoms. Schizophrenia is a mental disorder characterized by a chemical imbalance of the brain, leading to altered thoughts, behaviors, and perceptions. In this case, the command hallucinations to harm others are a symptom of the disorder. Choices B, C, and D are not accurate explanations for the client's condition.

Question 17

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

This response acknowledges the client's experience without validating the content of their delusions or hallucinations. It also provides reassurance that the nurse does not hear any voices, which may help to decrease the client's anxiety. The other options are not effective in addressing the client's statement or providing helpful support.

Question 18

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

Accepted Answer

Providing personal space allows the client to feel safe and respected, which can help decrease agitation and paranoia. Bright lights and constant eye contact may increase agitation, and therapeutic touch may not be appropriate if the client has issues with trust or boundaries.

Question 19

A client diagnosed with Schizophrenia is prescribed clozapine (Clozaril).Which client symptoms related to the side effects of this medication should prompt the nurse to intervene immediately?

Accepted Answer

Sore throat, fever, and malaise may indicate a potentially life-threatening side effect of clozapine called agranulocytosis, which is a significant decrease in white blood cells. The nurse should intervene immediately and notify the provider to discontinue the medication and monitor the client's CBC. Akathisia and hypersalivation, akinesia and insomnia, and dry mouth and urinary retention are common side effects of many antipsychotic medications, including clozapine, but do not require immediate intervention. The nurse should still monitor and report these side effects to the provider.

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." Which symptom is the client exhibiting,and what is the nurse's legal responsibility related to this symptom?

Accepted Answer

The client is exhibiting command hallucinations, which are potentially dangerous as they are urging the client to harm someone. The nurse has a legal responsibility to warn the psychiatrist of the potential danger.

Quiz 24: Schizophrenia Spectrum and Other Psychotic Disorders