CH 12 Schiz Spctrm DO Flashcards
A client has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today this client shouts, “They’re all plotting to destroy me. Isn’t that true?” what is the nurse’s most therapeutic response?
a. “Everyone here is trying to help you. No one wants to harm you.”
b. “Feeling that people want to destroy you must be very frightening.”
c. “That is not true. People here are trying to help you if you will let them.”
d. “Staff members are health care professionals who are qualified to help you.”
b. “Feeling that people want to destroy you must be very frightening.”
A newly admitted client diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The client states, “I saw two doctors talking in the hall. They were plotting to kill me.” The nurse may correctly assess this behavior using which term?
a. echolalia.
b. paranoia
c. a delusion of infidelity.
d. an auditory hallucination.
b. paranoia
A client diagnosed with schizophrenia says, “My co-workers are out to get me. I also saw two
doctors plotting to kill me.” How does this client perceive the environment?
a. Disorganized
b. Dangerous
c. Supportive
d. Bizarre
b. Dangerous
When a client diagnosed with schizophrenia was discharged 6 months ago, haloperidol was prescribed. The client now says, “I stopped taking those pills. They made me feel like a robot.” What are common side effects the nurse should validate with the client?
a. Sedation and muscle stiffness
b. Sweating, nausea, and diarrhea
c. Mild fever, sore throat, and skin rash
d. Headache, watery eyes, and runny nose
a. Sedation and muscle stiffness
Which hallucination expressed by a client necessitates the nurse to implement safety measures?
a. “I hear angels playing harps.”
b. “The voices say everyone is trying to kill me.”
c. “My dead father tells me I am a good person.”
d. “The voices talk only at night when I’m trying to sleep.”
b. “The voices say everyone is trying to kill me.”
A client’s care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the client may be hallucinating?
a. Detachment and overconfidence
b. Darting eyes, tilted head, mumbling to self
c. Euphoric mood, hyperactivity, distractibility
d. Foot tapping and repeatedly writing the same phrase
b. Darting eyes, tilted head, mumbling to self
A health care provider considers which antipsychotic medication to prescribe for a client diagnosed with schizophrenia who has auditory hallucinations and poor social function. The client is also overweight and hypertensive. Which drug should the nurse advocate?
a. Clozapine
b. Ziprasidone
c. Olanzapine
d. Aripiprazole
d. Aripiprazole
A client diagnosed with schizophrenia tells the nurse, “I eat skiller. Tend to end. Easter. It
blows away. Get it?” What is the nurse’s most therapeutic response?
a. “Nothing you are saying is clear.”
b. “Your thoughts are very disconnected.”
c. “Try to organize your thoughts and then tell me again.”
d. “I am having difficulty understanding what you are saying.”
d. “I am having difficulty understanding what you are saying.”
A client diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates
catatonia. Which client needs are of priority importance?
a. Self-esteem
b. Psychosocial
c. Physiological
d. Self-actualization
c. Physiological
A client diagnosed with schizophrenia demonstrates little spontaneous movement and has catatonia. The client’s activities of daily living are severely compromised. What will be an appropriate outcome for this client?
a. demonstrates increased interest in the environment by the end of week 1.
b. performs self-care activities with coaching by the end of day 3.
c. gradually takes the initiative for self-care by the end of week 2.
d. accepts tube feeding without objection by day 2.
b. performs self-care activities with coaching by the end of day 3.
A nurse observes a catatonic client standing immobile, facing the wall with one arm extended in a salute. The client remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon?
a. Echolalia
b. Catatonia
c. Depersonalization
d. Thought withdrawal
b. Catatonia
A nurse leads a psychoeducational group about first-generation antipsychotic medications with six adult men diagnosed with schizophrenia. The nurse will monitor for concerns regarding body image with respect to which potential side effect of these medications?
a. Constipation
b. Gynecomastia
c. Visual changes
d. Photosensitivity
b. Gynecomastia
A nurse leads a psychoeducational group about problem solving with six adults diagnosed with schizophrenia. Which teaching strategy is likely to be most effective?
a. Suggest analogies that might apply to a common daily problem.
b. Assign each participant a problem to solve independently and present to the group.
c. Ask each client to read aloud a short segment from a book about problem solving.
d. Invite participants to come up with solution to getting incorrect change for a
purchase.
d. Invite participants to come up with solution to getting incorrect change for a purchase.
A nurse educates a client about the antipsychotic medication regime. Afterward, which comment by the client indicates the teaching was effective?
a. “I will need higher and higher doses of my medication as time goes on.”
b. “I need to store my medication in a cool dark place, such as the refrigerator.”
c. “Taking this medication regularly will reduce the severity of my symptoms.”
d. “If I run out or stop taking my medication, I will experience withdrawal
symptoms.”
c. “Taking this medication regularly will reduce the severity of my symptoms.”
A newly admitted client diagnosed with schizophrenia says, “The voices are bothering me. They yell and tell me I am bad. I have got to get away from them.” Select the nurse’s most helpful reply.
a. “Do you hear the voices often?”
b. “Do you have a plan for getting away from the voices?”
c. “I’ll stay with you. Focus on what we are talking about, not the voices. ”
d. “Forget the voices and ask some other clients to play cards with you.”
c. “I’ll stay with you. Focus on what we are talking about, not the voices. ”
A client diagnosed with schizophrenia has taken fluphenazine 5 mg po bid for 3 weeks. The nurse now observes a shuffling propulsive gait, a mask-like face, and drooling. Which term applies to these symptoms?
a. Neuroleptic malignant syndrome
b. Hepatocellular effects
c. Pseudoparkinsonism
d. Akathisia
c. Pseudoparkinsonism
A client diagnosed with schizophrenia is very disturbed and violent. After several doses of haloperidol, the client is calm. Two hours later the nurse sees the client’s head rotated to one side in a stiff position, the lower jaw thrust forward, and drooling. Which problem is most likely?
a. An acute dystonic reaction
b. Tardive dyskinesia
c. Waxy flexibility
d. Akathisia
a. An acute dystonic reaction
An acutely violent client diagnosed with schizophrenia received several doses of haloperidol. Two hours later the nurse notices the client’s head rotated to one side in a stiffly fixed position, the lower jaw thrust forward, and drooling. Which intervention by the nurse is indicated?
a. Administer diphenhydramine 50 mg IM from the prn medication administration record.
b. Reassure the client that the symptoms will subside. Practice relaxation exercises with the client.
c. Give trihexyphenidyl 5 mg orally at the next regularly scheduled medication administration time.
d. Administer atropine sulfate 2 mg subcut from the prn medication administration record.
a. Administer diphenhydramine 50 mg IM from the prn medication administration record.
A client diagnosed with schizophrenia has received fluphenazine decanoate twice a month for 3 years. The clinic nurse notes that the client grimaces and constantly smacks both lips. The client’s neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect?
a. Agranulocytosis
b. Tardive dyskinesia
c. Tourette’s syndrome
d. Anticholinergic effects
b. Tardive dyskinesia
A nurse sits with a client diagnosed with schizophrenia. The client starts to laugh uncontrollably, although the nurse has not said anything funny. What is the nurse’s most therapeutic response?
a. “Why are you laughing?”
b. “Please share the joke with me.”
c. “I don’t think I said anything funny.”
d. “You’re laughing. Tell me what’s happening.”
d. “You’re laughing. Tell me what’s happening.”
The nurse assesses a client diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia?
a. Auditory hallucinations
b. Delusions of grandeur
c. Poor personal hygiene
d. Psychomotor agitation
c. Poor personal hygiene
What assessment findings mark the prodromal stage of schizophrenia?
a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion
b. Auditory hallucinations, ideas of reference, thought insertion, and broadcasting
c. Stereotyped behavior, echopraxia, echolalia, and waxy flexibility
d. Loose associations, concrete thinking, and echolalia neologisms
a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion
A client diagnosed with schizophrenia says, “Contagious bacteria are everywhere. When they get in your body, you will be locked up with other infected people.” Which problem is evident?
a. Poverty of content
b. Concrete thinking
c. Neologisms
d. Paranoia
d. Paranoia
A client diagnosed with schizophrenia begins a new prescription for ziprasidone. The client is 5’6’’ and currently weighs 204 lbs. The client has dry flaky skin, headaches about twice a month, and a family history of colon cancer. Which intervention has the highest priority for the nurse to include in the client’s plan of care?
a. Skin care techniques
b. Scheduling a colonoscopy
c. Weight management strategies
d. Teaching to limit caffeine intake
c. Weight management strategies
