Chapter 12 - Schizophrenia Spectrum Disorders

Question 1

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.”

Answer 1

b. “Feeling that people want to destroy you must be very frightening.”

Question 2

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.

Answer 2

b. paranoia

Question 3

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

Answer 3

b. Dangerous

Question 4

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

Answer 4

a. Sedation and muscle stiffness

Question 5

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.”

Answer 5

b. “The voices say everyone is trying to kill me.”

Question 6

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

Answer 6

b. Darting eyes, tilted head, mumbling to self

Question 7

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

Answer 7

d. Aripiprazole

Question 8

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.”

Answer 8

d. “I am having difficulty understanding what you are saying.”

Question 9

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

Answer 9

c. Physiological

Question 10

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.

Answer 10

b. performs self-care activities with coaching by the end of day 3.

Question 11

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

Answer 11

b. Catatonia

Question 12

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

Answer 12

b. Gynecomastia

Question 13

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.

Answer 13

d. Invite participants to come up with solution to getting incorrect change for a purchase.

Question 14

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.”

Answer 14

c. “Taking this medication regularly will reduce the severity of my symptoms.”

Question 15

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.”

Answer 15

c. “I’ll stay with you. Focus on what we are talking about, not the voices. ”

Question 16

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

Answer 16

c. Pseudoparkinsonism

Question 17

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

Answer 17

a. An acute dystonic reaction

Question 18

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.

Answer 18

a. Administer diphenhydramine 50 mg IM from the prn medication administration record.

Question 19

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

Answer 19

b. Tardive dyskinesia

Question 20

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.”

Answer 20

d. “You’re laughing. Tell me what’s happening.”

Question 21

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

Answer 21

c. Poor personal hygiene

Question 22

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

Answer 22

a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion

Question 23

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

Answer 23

d. Paranoia

Question 24

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

Answer 24

c. Weight management strategies

Question 25

A client diagnosed with schizophrenia says, “It’s beat. Time to eat. No room for the cat.” What type of verbalization is evident?

a. Neologism
b. Idea of reference
c. Thought broadcasting
d. Associative looseness

Answer 25

d. Associative looseness

Question 26

A client diagnosed with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive, but the client continues to have apathy, poverty of thought, and social isolation. The nurse would expect a change to which medication?

a. Haloperidol
b. Olanzapine
c. Chlorpromazine
d. Diphenhydramine

Answer 26

b. Olanzapine

Question 27

The family of a client diagnosed with schizophrenia is unfamiliar with the illness and family’s role in recovery. Which type of therapy should the nurse recommend?

a. Psychoeducational
b. Psychoanalytic
c. Transactional
d. Family

Answer 27

a. Psychoeducational

Question 28

A client diagnosed with schizophrenia has been stable for a year; however, the family now reports the client is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The client says, “My computer is sending out infected radiation beams.” The nurse can correctly assess this information as an indication of what?

a. the need for psychoeducation.
b. medication nonadherence.
c. chronic deterioration.
d. relapse.

Answer 28

d. relapse.

Question 29

A client diagnosed with schizophrenia begins to talks about “macnabs” hiding in the warehouse at work. The client’s use of “macnabs” should be documented using what term?

a. a neologism.
b. concrete thinking.
c. thought insertion.
d. an idea of reference.

Answer 29

a. a neologism.

Question 30

A client diagnosed with schizophrenia anxiously says, “I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror.” While listening, the nurse should engage in what behavior?

a. sit close to the client.
b. place an arm protectively around the client’s shoulders.
c. place a hand on the client’s arm and exert light pressure.
d. maintain a normal social interaction distance from the client.

Answer 30

a. sit close to the client.

Question 31

A client diagnosed with schizophrenia anxiously tells the nurse, “The voice is telling me to do things.” What is the nurse’s priority assessment question?

a. “How long has the voice been directing your behavior?”
b. “Does what the voice tell you to do frighten you?”
c. “Do you recognize the voice speaking to you?’
d. “What is the voice telling you to do?”

Answer 31

d. “What is the voice telling you to do?”

Question 32

A client receiving risperidone reports severe muscle stiffness at 1030. By 1200, the client has difficulty swallowing and is drooling. By 1600, vital signs are 102.8° F; pulse 110; respirations 26; 150/90. The client is diaphoretic. What is the nurse’s best analysis and action?

a. Agranulocytosis; institute reverse isolation.
b. Tardive dyskinesia; withhold the next dose of medication.
c. Cholestatic jaundice; begin a high-protein, high-cholesterol diet.
d. Neuroleptic malignant syndrome; notify health care provider stat.

Answer 32

d. Neuroleptic malignant syndrome; notify health care provider stat.

Question 33

A nurse asks a client diagnosed with schizophrenia, “What is meant by the old saying ‘You can’t judge a book by looking at the cover.’?” Which response by the client indicates concrete thinking?

a. “The table of contents tells what a book is about.”
b. “You can’t judge a book by looking at the cover.”
c. “Things are not always as they first appear.”
d. “Why are you asking me about books?”

Answer 33

a. “The table of contents tells what a book is about.”

Question 34

The nurse is developing a plan for psychoeducational sessions for a small group of adults diagnosed with schizophrenia. Which goal is best for this group’s members?

a. gain insight into unconscious factors that contribute to their illness.
b. explore situations that trigger hostility and anger.
c. learn to manage delusional thinking.
d. demonstrate improved social skills.

Answer 34

d. demonstrate improved social skills.

Question 35

A client says, “Facebook has a new tracking capacity. If I use the Internet, Homeland Security will detain me as a terrorist.” What is the nurse’s best initial action?

a. Tell the client, “Facebook is a safe website. You don’t need to worry about Homeland Security.”
b. Tell the client, “You are in a safe place where you will be helped.”
c. Administer a prn dose of an antipsychotic medication.
d. Tell the client, “You don’t need to worry about that.”

Answer 35

b. Tell the client, “You are in a safe place where you will be helped.”

Question 36

Which finding constitutes a negative symptom associated with schizophrenia?

a. Hostility
b. Bizarre behavior
c. Poverty of thought
d. Auditory hallucinations

Answer 36

c. Poverty of thought

Question 37

A client insistently states, “I can decipher codes of DNA just by looking at someone.” Which problem is evident?

a. Visual hallucinations
b. Magical thinking
c. Idea of reference
d. Thought insertion

Answer 37

b. Magical thinking

Question 38

A newly hospitalized client experiencing psychosis says, “Red chair out town board.” Which term should the nurse use to
document this finding?

a. Word salad
b. Neologism
c. Anhedonia
d. Echolalia

Answer 38

a. Word salad

Question 39

A nurse at the mental health clinic plans a series of psychoeducational groups for persons newly diagnosed with schizophrenia. Which two topics take priority? (Select all that apply.)

a. “The importance of taking your medication correctly”
b. “How to complete an application for employment”
c. “How to dress when attending community events”
d. “How to give and receive compliments”
e. “Ways to quit smoking”

Answer 39

a. “The importance of taking your medication correctly”
e. “Ways to quit smoking”

Question 40

A client diagnosed with schizophrenia was hospitalized after arguing with co-workers and threatening to harm them. The client is aloof, suspicious, and says, “Two staff members I saw talking were plotting to kill me.” Based on data gathered at this point, which nursing diagnoses relate? (Select all that apply.)

a. Risk for other-directed violence
b. Disturbed thought processes
c. Risk for loneliness
d. Spiritual distress
e. Social isolation

Answer 40

a. Risk for other-directed violence
b. Disturbed thought processes