Question 1

A client exhibits paranoia, bizarre behaviors, neologisms, and delusions of persecution. While eating breakfast in the dayroom, the client starts yelling at others. Which is the nurse's first action?

Accepted Answer

1.This is incorrect. Safety is always the nurse's priority. The nurse should move the other clients away from the client to protect them from harm. The nurse should check the client's mouth to ensure the client is swallowing each dose of medication; however, this should not be the first action. Medications must be ingested to achieve a therapeutic effect.
2.This is correct. Safety is always the nurse's priority. The nurse should move the other clients away from the client to protect them from harm.
3.This is incorrect. Safety is always the nurse's priority. The nurse should move the other clients away from the client to protect them from harm. The law requires the nurse to use less-restrictive interventions before utilizing restraints.
4.This is incorrect. Safety is always the nurse's priority. The nurse should move the other clients away from the client to protect them from harm, then move the client to a less-stimulating environment.

Question 2

A 16-year-old client diagnosed with schizophrenia is experiencing auditory command hallucinations. The client reports the voices are telling him to harm others. The client's parents ask the nurse, "Where do the voices come from?" Which is the nurse's most appropriate reply?

Accepted Answer

1.This is correct. Hallucinations are false sensory perceptions not associated with real external stimuli and may involve any of the five senses. Hallucinations are positive symptoms of schizophrenia related to increased production or release of dopamine at nerve terminals. Antipsychotic medications reduce psychotic symptoms by lowering brain levels of dopamine.
2.This is incorrect. The nurse's most appropriate reply is "Auditory hallucinations are caused by increased dopamine levels in the brain." Hallucinations are false sensory perceptions not associated with real external stimuli and may involve any of the five senses. Hallucinations are positive symptoms of schizophrenia related to increased production or release of dopamine at nerve terminals. Antipsychotic medications are used to treat symptoms of schizophrenia.
3.This is incorrect. The nurse's most appropriate nursing reply is "Auditory hallucinations are caused by increased dopamine levels in the brain." Hallucinations are false sensory perceptions not associated with real external stimuli and may involve any of the five senses. Hallucinations are positive symptoms of schizophrenia related to increased production or release of dopamine at nerve terminals. Excess serotonin levels are hypothesized to cause both positive and negative symptoms of schizophrenia as well as symptoms of depression.
4.This is incorrect. The nurse's most appropriate nursing reply is "Auditory hallucinations are caused by increased dopamine levels in the brain." Hallucinations are false sensory perceptions not associated with real external stimuli and may involve any of the five senses. Hallucinations are positive symptoms of schizophrenia related to increased production or release of dopamine at nerve terminals, not abnormal hormone changes.

Question 3

The nurse is educating the parents of a child diagnosed with schizophrenia on how to reply when their child experiences auditory hallucinations. Which is the nurse's best reply?

Accepted Answer

1.This is incorrect. This statement does not demonstrate empathy and ignores the child's feelings. The voices are real to the client; therefore, the nurse should encourage the parents to acknowledge the voices are real to the child, but let the child know they do not share the perception. Use of the word "voices" helps avoid reinforcing the hallucination.
2.This is correct. Safety is always the nurse's priority. The parents should ask what the voices are saying to identify whether the child is hearing commands to harm self or others. The nurse should encourage the parents to acknowledge the voices are real to the child, but let the child know they do not share the perception. Use of the word "voices" helps avoid reinforcing the hallucination.
3.This is incorrect. Safety is always the nurse's priority. The nurse should first assess whether the child is having command hallucinations and then encourage the parents to acknowledge the voices are real to the child, but let the child know they do not share the perception. Use of the word "voices" helps avoid reinforcing the hallucination.
4.This is incorrect. Hallucinations are frightening, and this statement ignores the child's feelings. Safety is always the nurse's priority. The parents should ask what the voices are saying to identify whether the child is hearing commands to harm self or others. The nurse should encourage the parents to acknowledge the voices are real to the child and also tell the child they do not hear them.

Question 4

The nurse is assessing a client diagnosed with schizophrenia and asks, "Do you ever get messages through things, like the television or microwave?" Which symptom of schizophrenia is the nurse assessing for?

Accepted Answer

1.This is incorrect. Illusions are misperceptions or misinterpretations of real external stimuli. The nurse is assessing for delusions of reference. Delusions are fixed false beliefs that are irrational that an individual maintains are true despite evidence to the contrary. Delusions of reference are characterized by an individual's perception that events within the environment have meaning specific to himself or herself.
2.This is incorrect. With circumstantiality, the individual delays in reaching the point of a communication because of unnecessary and tedious details. The nurse is assessing for delusions of reference. Delusions are fixed false beliefs that are irrational that an individual maintains are true despite evidence to the contrary. Delusions of reference are characterized by an individual's perception that events within the environment have meaning specific to himself or herself.
3.This is incorrect. Hallucinations are false sensory perceptions not associated with real external stimuli.The nurse is assessing for the positive symptom of delusions of reference. Delusions are fixed false beliefs that are irrational that an individual maintains despite evidence to the contrary. Delusions of reference are characterized by an individual's perception that events within the environment have meaning specific to himself or herself.
4.This is correct. The nurse is assessing for delusions of reference. Delusions are fixed false beliefs that an individual maintains are true despite evidence to the contrary. Delusions of reference are characterized by an individual's perception that events within the environment have meaning specific to himself or herself.

Question 5

The nurse is assessing a new client diagnosed with schizophrenia. The client states "Those people behind the desk won't stop laughing at me." The nurse determines the client is experiencing which symptom?

Accepted Answer

1.This is correct. The client is experiencing ideas of reference, which are characterized by an individual's belief that a neutral event within the environment has a special and personal meaning.
2.This is incorrect. The client is experiencing ideas of reference, which are characterized by an individual's belief that a neutral event within the environment has a special and personal meaning. Loose associations are characterized by speech in which an individual's ideas shift from one unrelated subject to another.
3.This is incorrect. The client is experiencing ideas of reference, which are characterized by an individual's belief that a neutral event within the environment has a special and personal meaning. Delusions of influence are characterized by an individual's belief that certain objects or persons have control over his or her behavior.
4.This is incorrect. The client is experiencing ideas of reference, which are characterized by an individual's belief that a neutral event within the environment has a special and personal meaning. Tangentiality is characterized by difficulty in maintaining focus and attention and veering away from the topic of discussion.

Question 6

A client diagnosed with brief psychotic disorder states, "The voices keep telling me I must kill the president." Which is the priority nursing diagnosis?

Accepted Answer

1.This is incorrect. Disturbed sensory perception addresses the presence of hallucinations. The priority nursing diagnosis is "risk for violence: other directed." The client is having auditory hallucinations commanding the client to kill the president. Others are at risk for harm should the client act on the commands. Safety is always the priority.
2.This is incorrect. The priority nursing diagnosis is "risk for violence: other directed." The client is having auditory hallucinations commanding the client to kill the president. Others are at risk for harm should the client act on the commands. Safety is always the priority. Disturbed thought processes are defined as disruptions in cognitive operations and activities as evidenced by behaviors that indicate the presence of delusional thinking, suspiciousness, and inaccurate interpretation of the environment.
3.This is correct. The priority nursing diagnosis is "risk for violence: other directed." The client is having auditory hallucinations commanding the client to kill the president. Others are at risk for harm should the client act on the commands. Safety is always the priority.
4.This is incorrect. Impaired verbal communication is defined as a state in which an individual experiences a decrease or absence of the ability to use or understand language. Hallucinations can impair the ability to effectively communicate. The priority nursing diagnosis is "risk for violence: other directed." The client is having auditory hallucinations commanding the client to kill the president. Others are at risk for harm should the client act on the commands. Safety is always the priority.

Question 7

The nurse notices a client is becoming very agitated. Which nursing intervention is most appropriate?

Accepted Answer

1.This is incorrect. 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 the client's risk for violence. A stimulating environment adds to anxiety and can increase the client's agitation.
2.This is incorrect. 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 the client's risk for violence. The client may feel threatened by continuous eye contact, and this can increase the client's agitation and paranoia.
3.This is incorrect. The client may feel threatened and become more agitated when touched. An agitated client's behavior is unpredictable, creating a risk of harm to self and others. 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 the client's risk for violence.
4.This is correct. 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 the client's risk for violence.

Question 8

Which nursing action is most appropriate to establish trust with a suspicious client?

Accepted Answer

1.This is incorrect. Use of passive communication is a patient-centered approach that helps establish trust and allows the patient the opportunity to make his or her decisions about activities and treatment goals. Consistency in staff also helps develop trust and decrease anxiety, but passive communication is most appropriate.
2.This is incorrect. Use of passive communication is a patient-centered approach that helps establish trust and allows the patient the opportunity to make his or her decisions about activities and treatment goals. Reinforcing and focusing on reality discourages ruminations on illogical thinking.
3.This is incorrect. Use of passive communication is a patient-centered approach that helps establish trust and allows the patient the opportunity to make his or her decisions about activities and treatment goals. Maintaining a low level of environmental stimuli helps decrease anxiety.
4.This is correct. Use of passive communication is a patient-centered approach that helps establish trust and allows the patient the opportunity to make his or her decisions about activities and treatment goals.

Question 9

The nurse expects a client experiencing prodromal symptoms of schizophrenia to demonstrate which of the following?

Accepted Answer

1.This is correct. An individual begins to show signs of significant deterioration in premorbid functioning during the prodromal phase of schizophrenia.
2.This is incorrect. An individual begins to show signs of significant deterioration in premorbid functioning during the prodromal phase of schizophrenia. Poor peer relationships are seen during the premorbid phase.
3.This is incorrect. An individual begins to show signs of significant deterioration in premorbid functioning during the prodromal phase of schizophrenia. Disturbances in thought processing and disorganized motor behavior are seen during the active psychotic phase.
4.This is incorrect. An individual begins to show signs of significant deterioration in premorbid functioning during the prodromal phase of schizophrenia. Disturbances in thought processing and disorganized motor behavior are seen during the active psychotic phase.

Question 10

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

Accepted Answer

1.This is correct. This statement indicates the client is experiencing a delusion. Delusions are fixed, false beliefs that are irrational and that the individual maintains are true despite evidence to the contrary.
2.This is incorrect. This statement is an example of an illusion. Illusions are misperceptions or misinterpretations of real external stimuli. "Spies are watching everything I do" is an example of a delusion. Delusions are fixed, false beliefs that are irrational and that the individual maintains are true despite evidence to the contrary.
3.This is incorrect. This statement indicates the client is experiencing a tactile hallucination. Tactile hallucinations are false perceptions of the sense of touch, often of something on or under the skin. "Spies are watching everything I do" is an example of a delusion. Delusions are fixed, false beliefs that are irrational and that the individual maintains are true despite evidence to the contrary.
4.This is incorrect. This statement is an example of avolition (lack of motivation), a negative symptom of schizophrenia. "Spies are watching everything I do" is an example of a delusion. Delusions are fixed, false beliefs that are irrational and that the individual maintains are true despite evidence to the contrary.

Question 11

The nurse observes that a client diagnosed with schizophrenia is slow to respond and appears to be listening to unseen others. Which medication does the nurse anticipate the provider will prescribe?

Accepted Answer

1.This is incorrect. The client is experiencing a hallucination. The nurse should expect the provider to order an antipsychotic. Risperidone is an atypical (newer-generation) antipsychotic, used to reduce positive symptoms, including disturbances in content of thought (delusions), form of thought (neologisms), or sensory perception (hallucinations). Benztropine is used to address symptoms of tardive dyskinesia.
2.This is incorrect. The client is experiencing a hallucination. The nurse should expect the provider to order an antipsychotic medication. Risperidone is an atypical (newer-generation) antipsychotic used to reduce positive symptoms of schizophrenia. Clonazepam is a benzodiazepine used to treat anxiety.
3.This is correct. The client is experiencing a hallucination. The nurse should expect the provider to order an antipsychotic medication. Risperidone is an atypical (newer-generation) antipsychotic used to reduce positive symptoms of schizophrenia.
4.This is incorrect. The client is experiencing a hallucination. The nurse should expect the provider to order an antipsychotic medication. Risperidone is an atypical (newer-generation) antipsychotic used to reduce positive symptoms of schizophrenia. Sertraline is a selective serotonin reuptake inhibitor antidepressant.

Question 12

The nurse is administering medications to a client experiencing acute psychosis. The client's medication orders include haloperidol 50 mg PO bid; benztropine 1 mg PO daily, and zolpidem 10 mg PO at bedtime daily. The nurse administers benztropine to address which of the following?

Accepted Answer

1.This is incorrect. Benztropine is an anticholinergic medication used for symptoms of tardive dyskinesia, characterized by abnormal involuntary movements. Tardive dyskinesia is a potentially irreversible adverse effect of antipsychotic medications. Antipsychotics are used to treat tactile and other types of hallucinations.
2.This is correct. Benztropine is an anticholinergic medication used for symptoms of tardive dyskinesia, characterized by abnormal involuntary movements. Tardive dyskinesia is a potentially irreversible adverse effect of antipsychotic medications.
3.This is incorrect. Benztropine is an anticholinergic medication used for symptoms of tardive dyskinesia, characterized by abnormal involuntary movements. Tardive dyskinesia is a potentially irreversible adverse effect of antipsychotic medications. Psychomotor retardation is a symptom of schizophrenia related to inadequate dopamine levels in the brain.
4.This is incorrect. Benztropine is an anticholinergic medication used for symptoms of tardive dyskinesia, characterized by abnormal involuntary movements. Tardive dyskinesia is a potentially irreversible adverse effect of antipsychotic medications. Pacing back and forth is a symptom of schizophrenia that can be attributed to anxiety.

Question 13

The nurse is providing discharge teaching to an elderly client diagnosed with schizophrenia. The client's medications include an antipsychotic (risperidone) and a beta-adrenergic blocking agent (propranolol). Which statement indicates the nurse understands the combined side effects of these medications?

Accepted Answer

1.This is incorrect. The nurse should instruct the client to rise slowly when changing positions. The combination of antipsychotic medications and beta blockers can lead to orthostatic hypotension, placing the client at risk for injury.
2.This is incorrect. The nurse should instruct the client to rise slowly when changing positions. The combination of antipsychotic medications and beta blockers can lead to orthostatic hypotension, placing the client at risk for injury. Limiting the intake of high-sugar foods helps prevent weight gain and hyperglycemia.
3.This is correct. The nurse should instruct the client to rise slowly when changing positions. The combination of antipsychotic medications and beta blockers can lead to orthostatic hypotension, placing the client at risk for injury.
4.This is incorrect. The nurse should instruct the client to rise slowly when changing positions. The combination of antipsychotic medications and beta blockers can lead to orthostatic hypotension, placing the client at risk for injury. Clients taking antipsychotic medications should avoid sun exposure.

Question 14

The nurse is reviewing the provider's orders for a client experiencing acute psychosis. The client's family tells the nurse the client has allergies to penicillin, prochlorperazine, and bee stings. Which medication order should the nurse question?

Accepted Answer

1.This is incorrect. Prochlorperazine and thioridazine are both classified as phenothiazines. They are contraindicated because there is cross-sensitivity among phenothiazines. Haloperidol is a typical antipsychotic medication, not a phenothiazine.
2.This is incorrect. Prochlorperazine and thioridazine are both classified as phenothiazines. They are contraindicated because there is cross-sensitivity among phenothiazines. Clozapine is a newer-generation antipsychotic medication, not a phenothiazine.
3.This is incorrect. Prochlorperazine and thioridazine are both classified as phenothiazines. They are contraindicated because there is cross-sensitivity among phenothiazines. Risperidone is a newer-generation antipsychotic medication, not a phenothiazine.
4.This is correct. Prochlorperazine and thioridazine are both classified as phenothiazines. They are contraindicated because there is cross-sensitivity among phenothiazines.

Question 15

The nurse is caring for a college student who started hearing voices, has not attended classes for the past 4 weeks, was yelling accusations at others, and has stopped communicating with family and friends. Which is the nurse's priority nursing diagnosis?

Accepted Answer

1.This is incorrect. The priority nursing diagnosis is "risk for other-directed violence R/T yelling accusations." Safety is always the priority. Verbal aggression is a behavior indicating risk for violence. The client's agitation indicates there is a potential for violence. Altered thought processes is an appropriate nursing diagnosis but does not take priority over risk of harm to others.
2.This is correct. The priority nursing diagnosis is "risk for other-directed violence R/T yelling accusations." Safety is always the priority. Verbal aggression is a behavior indicating risk for violence. Other risk factors include aggressive body language, command hallucinations, rage reactions, and destruction of objects in the environment.
3.This is incorrect. The priority nursing diagnosis is "risk for other-directed violence R/T yelling accusations." Safety is always the priority. Verbal aggression is a behavior indicating risk for violence. Social isolation and paranoia do not take priority over the risk for other-directed violence.
4.This is incorrect. The priority nursing diagnosis is "risk for other-directed violence R/T yelling accusations." Safety is always the priority. Verbal aggression is a behavior indicating risk for violence. The client's current symptoms do not support this nursing diagnosis.

Question 16

The nurse is admitting a client to the inpatient psychiatric unit. Which intervention is most appropriate to reduce the client's delusional thinking?

Accepted Answer

1.This is incorrect. Delusions are fixed false beliefs that are irrational that an individual maintains are true despite evidence to the contrary. The individual continues to have the beliefs despite obvious proof that they are false or irrational. Logical evidence will not change the client's perception of reality.
2.This is correct. Delusions are fixed false beliefs that are irrational that an individual maintains are true despite evidence to the contrary. The individual continues to have the beliefs despite obvious proof that they are false or irrational. The nurse should focus on the client's feelings.
3.This is incorrect. Delusions are fixed false beliefs that are irrational that an individual maintains are true despite evidence to the contrary. The individual continues to have the beliefs despite obvious proof that they are false or irrational. Neither evidence nor logical explanations are likely to alter the client's beliefs.
4.This is incorrect. Delusions are fixed false beliefs that are irrational that an individual maintains are true despite evidence to the contrary. The individual continues to have the beliefs despite obvious proof that they are false or irrational. Focusing on the content of the delusion reinforces the client's irrational thinking.

Question 17

A client states, "The voices keep saying I am evil." Which outcome criteria is most important to include in the client's plan of care?

Accepted Answer

1.This is incorrect. The most important outcome is that the client can identify factors that increase anxiety and trigger hallucinations. Symptoms of psychosis may be minimized or prevented if the client learns techniques to interrupt escalating anxiety. Preventing symptoms is most important, as the client will be able to interpret the environment correctly when symptoms are managed.
2.This is incorrect. The most important outcome is that the client can identify factors that increase anxiety and trigger hallucinations. Symptoms of psychosis may be minimized or prevented if the patient can learn techniques to interrupt escalating anxiety. Preventing symptoms allows the client to effectively communicate with others.
3.This is correct. The most important outcome is that the client can identify factors that increase anxiety and trigger hallucinations. Symptoms of psychosis may be minimized or prevented if the patient can learn techniques to interrupt escalating anxiety.
4.This is incorrect. The most important outcome is that the client can identify factors that increase anxiety and trigger hallucinations. Symptoms of psychosis may be minimized or prevented if the patient can learn techniques to interrupt escalating anxiety. The client will be able to better relate to others.

Question 18

A newly admitted client exhibits symptoms of paranoia and hallucinations. The client's spouse states, "I don't understand. My spouse hasn't hallucinated since the doctor prescribed thioridazine 2 years ago." The nurse recognizes which as the most likely explanation for the recurrence of the client's symptoms?

Accepted Answer

1.This is incorrect. Altered thinking can affect a client's insight into the necessity for taking antipsychotic medications consistently. Tolerance develops over time and is evident when increasing doses of medication are needed to achieve the medication's initial effect.
2.This is incorrect. Altered thinking can affect a client's insight into the necessity for taking antipsychotic medications consistently. An individual's lack of awareness of having an illness or disorder is the most common predictor of nonadherence to treatment and a poorer course of illness. Though taking medication with food may alter the absorption rate of the medication, some medication is in the client's system.
3.This is correct. Altered thinking can affect a client's insight into the necessity for taking antipsychotic medications consistently. An individual's lack of awareness of having an illness or disorder is the most common predictor of nonadherence to treatment and a poorer course of illness.
4.This is incorrect. Altered thinking can affect a client's insight into the necessity for taking antipsychotic medications consistently. An individual's lack of awareness of having an illness or disorder is the most common predictor of nonadherence to treatment and a poorer course of illness. Alcohol use may create symptoms similar to those of schizophrenia.

Question 19

The nursing instructor asks a nursing student to describe concepts of the Recovery Model. Which concepts should the nursing student include? Select all that apply.

Accepted Answer

1.This is incorrect. The Recovery Model highlights the dimension of active engagement and empowerment of the client in decision making. The client identifies goals based on personal values or what they define as giving meaning and purpose to life. Behavior therapy attaches positive, negative, and aversive reinforcements to adaptive and maladaptive behaviors.
2.This is correct. The Recovery Model highlights the dimension of active engagement. The client identifies goals based on personal values or what they define as giving meaning and purpose to life.
3.This is incorrect. The Recovery Model highlights the dimension of active engagement and empowerment of the client in decision-making. The client identifies goals based on personal values or what they define as giving meaning and purpose to life. Milieu therapy focuses on a client's interaction within a social environment.
4.This is incorrect. The Recovery Model highlights empowering the client in decision-making. Family therapy focuses on improving adherence to prescribed medications.
5.This is correct. The Recovery Model highlights the dimension of active engagement and empowerment of the client in decision making. The client identifies goals based on personal values or what he or she defines as giving meaning and purpose to life.

Quiz 10: Schizophrenia Spectrum and Other Psychotic Disorders