Chapter 15: Schizophrenia Spectrum and Other Psychotic Disorders

Question 1

A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client’s safety?

1. Assess for medication nonadherance.
2. Note escalating behaviors and intervene immediately.
3. Interpret attempts at communication.
4. Assess triggers for bizarre, inappropriate behaviors.

Answer 1

ANS: 2
Rationale: The nurse should note escalating behaviors and intervene immediately, to maintain this client’s safety. Early intervention may prevent an aggressive response and keep the client and others safe.

Question 2

A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be included in the nurse’s teaching?

1. The side effects of medications
2. Deep breathing techniques to decrease stress
3. How to make eye contact when communicating
4. How to be a leader

Answer 2

ANS: 3
Rationale: The nurse should plan to teach the client how to make eye contact when communicating. Social skills, such as making eye contact, can assist clients to communicate needs and to establish relationships.

Question 3

A 16-year-old client diagnosed with schizophrenia spectrum disorder experiences command hallucinations to harm others. The client’s parents ask a nurse, “Where do the voices come from?” Which is the appropriate nursing response?

1. “Your child has a chemical imbalance of the brain, which leads to altered perceptions.”
2. “Your child’s hallucinations are caused by medication interactions.”
3. “Your child has too little serotonin in the brain, causing delusions and hallucinations.”
4. “Your child’s abnormal hormonal changes have precipitated auditory hallucinations.”

Answer 3

ANS: 1
Rationale: The nurse should explain that a chemical imbalance of the brain leads to altered perceptions. Hallucinations, or false sensory perceptions, may occur in all five senses. The client hearing voices is experiencing an auditory hallucination.

Question 4

Parents ask a nurse how they should reply when their child, diagnosed with schizophrenia spectrum disorder, tells them that voices command him to harm others. Which is the appropriate nursing response?

1. “Tell him to stop discussing the voices.”
2. “Ignore what he is saying, while attempting to discover the underlying cause.”
3. “Focus on the feelings generated by the hallucinations and present reality.”
4. “Present objective evidence that the voices are not real.”

Answer 4

ANS: 3
Rationale: The most appropriate response by the nurse is to instruct the parents to focus on the feelings generated by the hallucinations and present reality. The parents should accept that their child is experiencing the hallucination but should not reinforce this unreal sensory perception.

Question 5

A nurse is assessing a client diagnosed with schizophrenia spectrum disorder. The nurse asks the client, “Do you receive special messages from certain sources, such as the television or radio?” The nurse is assessing which potential symptom of this disorder?

1. Thought insertion
2. Paranoid delusions
3. Magical thinking
4. Delusions of reference

Answer 5

ANS: 4
Rationale: The nurse is assessing for the potential symptom of delusions of reference. A client that believes he or she receives messages through the radio is experiencing delusions of reference. These delusions involve the client interpreting events within the environment as being directed toward him- or herself.

Question 6

A client diagnosed with schizophrenia spectrum disorder 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 response?

1. “Did you take your medicine this morning?”
2. “You are not going to hell. You are a good person.”
3. “The voices must sound scary, but the devil is not talking to you. This is part of your illness.”
4. “The devil only talks to people who are receptive to his influence.”

Answer 6

ANS: 3
Rationale: The most appropriate nursing response is to reassure the client while not reinforcing the hallucination. Reminding the client that “the voices” are a part of the illness is a way to help the client accept that the hallucinations are not real. It is also important for the nurse to connect with the client’s fears and inner feelings.

Question 7

A client diagnosed with schizophrenia spectrum disorder tells a nurse about voices commanding him to kill the president. Which is the priority nursing diagnosis for this client?

1. Disturbed sensory perception
2. Altered thought processes
3. Risk for violence: directed toward others
4. Risk for injury

Answer 7

ANS: 3
Rationale: The nurse should prioritize the diagnosis risk for violence: directed toward others. A client who hears voices commanding him to kill someone is at risk for other-directed violence. Other risk factors for violence include aggressive body language, verbal aggression, catatonic excitement, and rage reactions.

Question 8

Which nursing intervention would be most appropriate when caring for an acutely agitated paranoid client diagnosed with schizophrenia spectrum disorder?

1. Provide neon lights and soft music.
2. Maintain continual eye contact throughout the interview.
3. Use therapeutic touch to increase trust and rapport.
4. Provide personal space to respect the client’s boundaries.

Answer 8

ANS: 4
Rationale: 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 thus reduce the client’s risk for violence.

Question 9

Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia spectrum disorder?

1. Establishing personal contact with family members
2. Being reliable, honest, and consistent during interactions
3. Sharing limited personal information
4. Sitting close to the client to establish rapport

Answer 9

ANS: 2
Rationale: The nurse can enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia spectrum disorder by being reliable, honest, and consistent during interactions. The nurse should also convey acceptance of the client’s needs and maintain a calm attitude when dealing with agitated behavior.

Question 10

A paranoid client diagnosed with schizophrenia spectrum disorder 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?

1. Magical thinking; administer an antipsychotic medication.
2. Persecutory delusions; orient the client to reality.
3. Command hallucinations; warn the psychiatrist.
4. Altered thought processes; call an emergency treatment team meeting.

Answer 10

ANS: 3
Rationale: The nurse should determine that the client is exhibiting command hallucinations. The nurse’s legal responsibility is to warn the psychiatrist of the potential for harm. Clients demonstrating a risk for violence could potentially be physically, emotionally, and/or sexually harmful to others or to self.

Question 11

A client is diagnosed with schizophrenia spectrum disorder. 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?

1. Tactile hallucinations
2. Tardive dyskinesia
3. Restlessness and muscle rigidity
4. Reports of hearing disturbing voices

Answer 11

ANS: 3
Rationale: The symptom of tactile hallucinations and reports of hearing disturbing voices would be addressed by an antipsychotic medication such as haloperidol. Tardive dyskinesia, a potentially irreversible condition, would warrant the discontinuation of an antipsychotic medication such as haloperidol. An anticholinergic medication such as benztropine would be used to treat the extrapyramidal symptoms of restlessness and muscle rigidity.

Question 12

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?

1. Paranoid delusions, anhedonia, and anergia are positive symptoms of schizophrenia.
2. Paranoid delusions, neologisms, and echolalia are positive symptoms of schizophrenia.
3. Paranoid delusions, anergia, and echolalia are negative symptoms of schizophrenia.
4. Paranoid delusions, flat affect, and anhedonia are negative symptoms of schizophrenia.

Answer 12

ANS: 2
Rationale: The nurse should recognize that positive symptoms of schizophrenia include, but are not limited to, paranoid delusions, neologisms, and echolalia. The negative symptoms of schizophrenia include, but are not limited to, flat affect, anhedonia, and anergia. Positive symptoms reflect an excess or distortion of normal functions. Negative symptoms reflect a diminution or loss of normal functions.

Question 13

A 60-year-old client diagnosed with schizophrenia spectrum disorder presents in an ED with uncontrollable tongue movements, stiff neck, and difficulty swallowing. Which medical diagnosis and treatment should a nurse anticipate when planning care for this client?

1. Neuroleptic malignant syndrome treated by discontinuing antipsychotic medications
2. Agranulocytosis treated by administration of clozapine (Clozaril)
3. Extrapyramidal symptoms treated by administration of benztropine (Cogentin)
4. Tardive dyskinesia treated by discontinuing antipsychotic medications

Answer 13

ANS: 4
Rationale: The nurse should expect that an ED physician would diagnose the client with tardive dyskinesia and discontinue antipsychotic medication. Tardive dyskinesia is a condition of abnormal involuntary movements of the mouth, tongue, trunk, and extremities that can be a side effect of typical antipsychotic medications.

Question 14

After taking chlorpromazine (Thorazine) for 1 month, a client presents to an ED with severe muscle rigidity, tachycardia, and a temperature of 105oF (40.5°C). Which medical diagnosis and treatment should a nurse anticipate when planning care for this client?

1. Neuroleptic malignant syndrome treated by discontinuing Thorazine and administering dantrolene (Dantrium)
2. Neuroleptic malignant syndrome treated by increasing Thorazine dosage and administering an antianxiety medication
3. Dystonia treated by administering trihexyphenidyl (Artane)
4. Dystonia treated by administering bromocriptine (Parlodel)

Answer 14

ANS: 1
Rationale: The nurse should expect that an ED physician would diagnose the client with neuroleptic malignant syndrome and treat the client by discontinuing chlorpromazine and administering dantrolene. Neuroleptic malignant syndrome is a potentially fatal condition characterized by rigidity, fever, altered consciousness, and autonomic instability. The use of typical antipsychotics is largely being replaced by atypical antipsychotics because they have fewer side effects and present a lower risk.

Question 15

A client diagnosed with schizophrenia spectrum disorder takes an antipsychotic agent daily. Which assessment finding should a nurse prioritize?

1. Respirations of 22 beats/minute
2. Weight gain of 8 pounds in 2 months
3. Temperature of 104°F (40°C)
4. Excessive salivation

Answer 15

ANS: 3
Rationale: When assessing a client diagnosed with schizophrenia spectrum disorder who takes an antipsychotic agent daily, the nurse should immediately address a temperature of 104°F (40°C). A temperature this high may indicate neuroleptic malignant syndrome, a life-threatening side effect of antipsychotic medications.

Question 16

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

1. “Make sure you concentrate on taking slow, deep, cleansing breaths.”
2. “Watch your diet and try to engage in some regular physical activity.”
3. “Rise slowly when you change position from lying to sitting or sitting to standing.”
4. “Wear sunscreen and try to avoid midday sun exposure.”

Answer 16

ANS: 3
Rationale: The most appropriate statement by the nurse is to instruct the client to rise slowly when changing positions. Antipsychotic medications and beta blockers cause a decrease in blood pressure. When given in combination, the additive effect of these drugs places the client at risk for developing orthostatic hypotension.

Question 17

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

1. Sore throat, fever, and malaise
2. Akathisia and hypersalivation
3. Akinesia and insomnia
4. Dry mouth and urinary retention

Answer 17

ANS: 1
Rationale: The nurse should intervene immediately if the client experiences signs of an infectious process, such as a sore throat, fever, and malaise, when taking the atypical antipsychotic drug clozapine. Clozapine can have a serious side effect of agranulocytosis, in which a potentially fatal drop in white blood cells can occur, leading to infection.

Question 18

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

1. Haloperidol (Haldol), because it is used only in older patients
2. Clozapine (Clozaril), because it is incompatible with desipramine
3. Risperidone (Risperdal), because it exacerbates symptoms of depression
4. Thioridazine (Mellaril), because of cross-sensitivity among phenothiazines

Answer 18

ANS: 4
Rationale: The nurse should know that thioridazine would be contraindicated because of cross-sensitivity among phenothiazines. Prochlorperazine and thioridazine are both classified as phenothiazines.

Question 19

A client has been assigned an admission diagnosis of brief psychotic disorder. Which assessment information would alert the nurse to question this diagnosis?

1. The client has experienced impaired reality testing for a 24-hour period.
2. The client has experienced auditory hallucinations for the past 3 hours.
3. The client has experienced bizarre behavior for 1 day.
4. The client has experienced confusion for 3 weeks.

Answer 19

ANS: 2
Rationale: This disorder is identified by the sudden onset of psychotic symptoms that may or may not be preceded by a severe psychosocial stressor. These symptoms last at least 1 day but less than 1 month.

Question 20

A nurse is assessing a client diagnosed with substance induced psychotic disorder (SIPD). What would differentiate this client’s symptoms from the symptoms of a client diagnosed with brief psychotic disorder (BPD)?

1. Clients diagnosed with SIPD experience delusions, whereas clients diagnosed with BPD do not.
2. Clients diagnosed with BPD experience hallucinations, whereas clients diagnosed with SIPD do not.
3. Catatonic features may be associated with SIPD, whereas BPD has no catatonic features.
4. Catatonic features may be associated with BPD, whereas SIPD has no catatonic features.

Answer 20

ANS: 3
Rationale: The diagnosis of SIPD is made when symptoms are directly attributable to substance intoxication or withdrawal. The symptoms are more excessive and more severe than those usually associated with the intoxication or withdrawal syndrome. Hallucinations and delusions are associated with both SIPD and BPD. Catatonic features may be associated with SIPD, whereas BPD has no catatonic features.

Question 21

A nurse prepares to assess a client using the Abnormal Involuntary Movement Scale (AIMS). Which side effect of antipsychotic medications led to the use of this assessment tool?

1. Dystonia
2. Tardive dyskinesia
3. Akinesia
4. Akathisia

Answer 21

ANS: 2
Rationale: The AIMS is a rating scale that was developed in the 1970s by the National Institute of Mental Health to measure involuntary movements associated with tardive dyskinesia.

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 spectrum disorder? (Select all that apply.)

1. Group therapy
2. Medication management
3. Deterrent therapy
4. Supportive family therapy
5. Social skills training

Answer 22

ANS: 1, 2, 4, 5
Rationale: The nurse should recognize that group therapy, medication management, supportive family therapy, and social skills training all play an integral part of rehabilitative programs for clients diagnosed with schizophrenia spectrum disorder. Schizophrenia results from various combinations of genetic predispositions, biochemical dysfunctions, physiological factors, and psychological stress. Effective treatment requires a comprehensive, multidisciplinary effort.

Question 23

A nurse is administering risperidone (Risperdal) to a client diagnosed with schizophrenia spectrum disorder. Which of the following client symptoms would most likely decrease because of the therapeutic effect of this medication? (Select all that apply.)

1. Somatic delusions
2. Social isolation
3. Gustatory hallucinations
4. Flat affect
5. Clang associations

Answer 23

ANS: 1, 3, 5
Rationale: The nurse should expect that risperidone would be effective treatment for the positive symptoms of somatic delusions, gustatory hallucinations, and clang associations. Risperidone is an atypical antipsychotic that has been effective in the treatment of the positive symptoms of schizophrenia and in maintenance therapy to prevent exacerbation of schizophrenic symptoms.

Question 24

Laboratory results reveal decreased levels of prolactin in a client diagnosed with schizophrenia spectrum disorder. Which of the following client symptoms would a nurse expect to observe during assessment? (Select all that apply.)

1. Apathy
2. Social withdrawal
3. Anhedonia
4. Auditory hallucinations
5. Delusions

Answer 24

ANS: 1, 2, 3
Rationale: The nurse should expect that a client with decreased levels of prolactin may experience apathy, social withdrawal, and anhedonia. Decreased levels of prolactin can cause depression, which could result in these symptoms.

Question 25

The diagnosis of catatonic disorder associated with another medical condition is made when the client’s medical history, physical examination, or laboratory findings provide evidence that symptoms are directly attributed to which of the following? (Select all that apply.)

1. Hyperthyroidism
2. Hypothyroidism
3. Hyperadrenalism
4. Hypoadrenalism
5. Hyperaphia

Answer 25

ANS: 1, 2, 3, 4
Rationale: The diagnosis of catatonic disorder associated with another medical condition is made when the symptomatology is evidenced from medical history, physical examination, or laboratory findings to be directly attributable to the physiological consequences of a general medical condition. Types of medical conditions that have been associated with catatonic disorder include metabolic disorders (e.g., hepatic encephalopathy, hypo- and hyperthyroidism, hypo- and hyperadrenalism, and vitamin B12 deficiency) and neurological conditions (e.g., epilepsy, tumors, cerebrovascular disease, head trauma, and encephalitis). Hyperaphia is an excessive sensitivity to touch.