Chapter 24

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?

Answer 1

B. Note escalating behaviors and intervene immediately

Question 2

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

Answer 2

C. How to make eye contact when communicating

Question 3

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

Answer 3

A. “Your child has a chemical imbalance of the brain, which leads to altered thoughts.”

Question 4

Parents ask a 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?

Answer 4

C. “Focus on the feelings generated by the hallucinations and present reality.”

Question 5

A 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 of this disorder is the nurse assessing?

Answer 5

D. Delusions of reference

Question 6

A client diagnosed with schizophrenia tells a nurse, “The ‘Shopatouliens’ took my shoes out of my room last night.” Which is an appropriate charting entry to describe this client’s statement?

Answer 6

B. “The client is expressing a neologism.”

Question 7

During an admission assessment, a 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?

Answer 7

B. Delusions of influence

Question 8

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?

Answer 8

C. “I’m sure the voices sound scary. I don’t hear any voices speaking.”

Question 9

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

Answer 9

C. Risk for violence: directed toward others

Question 10

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

Answer 10

D. Provide personal space to respect the client’s boundaries.

Question 11

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

Answer 11

B. Being reliable, honest, and consistent during interactions.

Question 12

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.” What symptom is the client exhibiting, and what is the nurse’s legal responsibility related to this symptom?

Answer 12

C. Command hallucinations; warn the psychiatrist

Question 13

Which statement should indicate to a nurse that an individual is experiencing a delusion?

Answer 13

A. “There’s an alien growing in my liver.”

Question 14

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

Answer 14

C. Risperidone (Risperdal) to address the positive symptom

Question 15

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?

Answer 15

C. Restlessness and muscle rigidity

Question 16

A 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?

Answer 16

B. Paranoia, neologisms, and echolalia are positive symptoms of schizophrenia.

Question 17

A client diagnosed with schizophrenia, who has been taking antipsychotic medication for the last 5 months, presents in an emergency department (ED) with uncontrollable tongue movements, stiff neck, and difficulty swallowing. The nurse would expect the physician to recognize which condition and implement which treatment?

Answer 17

D. Tardive dyskinesia, treated by discontinuing antipsychotic medications

Question 18

A client who is admitted to the inpatient psychiatric unit and is taking Thorazine presents to the nurse with severe muscle rigidity, tachycardia, and a temperature of 105F (40.5C). The nurse identifies these symptoms as which of the following conditions?

Answer 18

A. Neuroleptic malignant syndrome

Question 19

A client diagnosed with schizophrenia takes an antipsychotic agent daily. Which assessment finding should a nurse immediately report to the client’s attending psychiatrist?

Answer 19

C. Temperature of 104F (40C)

Question 20

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, the nurse would most appropriately make which statement?

Answer 20

C. “Rise slowly when you change position from lying to sitting or sitting to standing.”

Question 21

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

Answer 21

A. Sore throat, fever, and malaise

Question 22

If clozapine (Clozaril) therapy is being considered, the nurse should evaluate which laboratory test to establish a baseline for comparison in order to recognize a potentially life-threatening side effect?

Answer 22

A. White blood cell count

Question 23

During an admission assessment, a nurse notes that a client diagnosed with schizophrenia has allergies to penicillin, prochlorperazine (Compazine), and bee stings. On the basis of this assessment data, which antipsychotic medication would be contraindicated?

Answer 23

D. Thioridazine (Mellaril), because of cross-sensitivity among phenothiazines

Question 24

A college student has quit attending classes, isolates self because of hearing voices, and yells accusations at fellow students. Based on this information, which nursing diagnosis should the nurse prioritize?

Answer 24

B. Risk for other-directed violence R/T yelling accusations

Question 25

A client has been recently admitted to an inpatient psychiatric unit. Which intervention should the nurse plan to use to reduce the client’s focus on delusional thinking?

Answer 25

B. Focus on feelings suggested by the delusion

Question 26

A client states, “I hear voices that tell me that I am evil.” Which outcome related to these symptoms should the nurse expect this client to accomplish by discharge?

Answer 26

C. The client will identify events that increase anxiety and illicit hallucinations.

Question 27

A newly admitted client has taken thioridazine (Mellaril) for 2 years, with good symptom control. Symptoms exhibited on admission included paranoia and hallucinations. The nurse should recognize which potential cause for the return of these symptoms?

Answer 27

C. The client has not taken the medication as prescribed.

Question 28

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? Select all that apply.

A. Group therapy
B. Medication management
C. Deterrent therapy
D. Supportive family therapy
E. Social skills training

Answer 28

A, B, D, E

Question 29

A nurse is administering risperidone (Risperdal) to a client diagnosed with schizophrenia. The therapeutic effect of this medication would most effectively address which of the following symptoms? Select all that apply.

A. Somatic delusions
B. Social isolation
C. Gustatory hallucinations
D. Flat affect
E. Clang associations

Answer 29

A, C, E

Question 30

Laboratory results reveal elevated levels of prolactin in a client diagnosed with schizophrenia. When assessing the client, the nurse should expect to observe which symptoms? Select all that apply.

A. Apathy
B. Social withdrawal
C. Anhedonia
D. Galactorrhea
E. Gynecomastia

Answer 30

D, E