Chapter 24- T

Question 1

1. A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client’s safety?
   A. Assess for medication noncompliance
   B. Note escalating behaviors and intervene immediately
   C. Interpret attempts at communication
   D. Assess triggers for bizarre, inappropriate behaviors

Answer 1

ANS: B
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

2. A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be taught by the nurse?
   A. The side effects of medications
   B. Deep breathing techniques to decrease stress
   C. How to make eye contact when communicating
   D. How to be a leader

Answer 2

ANS: C
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 in communicating needs and maintaining connectedness.

Question 3

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?
   A. “Your child has a chemical imbalance of the brain, which leads to altered thoughts.”
   B. “Your child’s hallucinations are caused by medication interactions.”
   C. “Your child has too little serotonin in the brain, causing delusions and hallucinations.”
   D. “Your child’s abnormal hormonal changes have precipitated auditory hallucinations.”

Answer 3

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

Question 4

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

Answer 4

ANS: C
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 maintain an attitude of acceptance to encourage communication but should not reinforce the hallucinations by exploring details of content. It is inappropriate to present logical arguments to persuade the client to accept the hallucinations as not real.

Question 5

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? 
A. Thought insertion
B. Paranoia
C. Magical thinking
D. Delusions of reference

Answer 5

ANS: D
The nurse is assessing for the potential symptom of delusions of reference. A client who believes that he or she receives messages through the radio is experiencing delusions of reference. When a client experiences these delusions, he or she interprets all events within the environment as personal references.

Question 6

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?
   A. “The client is experiencing command hallucinations.”
   B. “The client is expressing a neologism.”
   C. “The client is experiencing a paranoia.”
   D. “The client is verbalizing a word salad.”

Answer 6

ANS: B
The nurse should describe the client’s statement as experiencing a neologism. A neologism is when a client invents a new word that is meaningless to others but may have symbolic meaning to the client. Word salad refers to a group of words that are put together randomly.

Question 7

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?
A. Delusions of persecution
B. Delusions of influence
C. Delusions of reference
D. Delusions of grandeur

Answer 7

ANS: B
The nurse is assessing the client for delusions of influence when asking if the client has ever felt that objects or persons have control of the client’s behavior. Delusions of control or influence are manifested when the client believes that his or her behavior is being influenced. An example would be if a client believes that a hearing aid receives transmissions that control personal thoughts and behaviors.

Question 8

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?
   A. “Did you take your medicine this morning?”
   B. “You are not going to hell. You are a good person.”
   C. “I’m sure the voices sound scary. I don’t hear any voices speaking.”
   D. “The devil only talks to people who are receptive to his influence.”

Answer 8

ANS: C
The most appropriate reply by the nurse is to reassure the client with an accepting attitude while not reinforcing the hallucination.

Question 9

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?
   A. Disturbed sensory perception
   B. Altered thought processes
   C. Risk for violence: directed toward others
   D. Risk for injury

Answer 9

ANS: C
The nurse should prioritize the diagnosis risk for violence: directed toward others. A client who hears voices telling him to kill someone is at risk for responding and reacting to the command hallucination. Other risk factors for violence include aggressive body language, verbal aggression, catatonic excitement, and rage reactions.

Question 10

10. Which nursing intervention would be most appropriate when caring for an acutely agitated client with paranoia?
    A. Provide neon lights and soft music.
    B. Maintain continual eye contact throughout the interview.
    C. Use therapeutic touch to increase trust and rapport.
    D. Provide personal space to respect the client’s boundaries.

Answer 10

ANS: D
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 11

11. Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia?
    A. Establishing personal contact with family members.
    B. Being reliable, honest, and consistent during interactions.
    C. Sharing limited personal information.
    D. Sitting close to the client to establish rapport.

Answer 11

ANS: B
The nurse can enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia 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 12

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?
    A. Magical thinking; administer an antipsychotic medication
    B. Persecutory delusions; orient the client to reality
    C. Command hallucinations; warn the psychiatrist
    D. Altered thought processes; call an emergency treatment team meeting

Answer 12

ANS: C
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. A client who is demonstrating a risk for violence could potentially become physically, emotionally, and/or sexually harmful to others or to self.

Question 13

13. Which statement should indicate to a nurse that an individual is experiencing a delusion?
    A. “There’s an alien growing in my liver.”
    B. “I see my dead husband everywhere I go.”
    C. “The IRS may audit my taxes.”
    D. “I’m not going to eat my food. It smells like brimstone.”

Answer 13

ANS: A
The nurse should recognize that a client who claims that an alien is inside his or her body is experiencing a delusion. Delusions are false personal beliefs that are inconsistent with the person’s intelligence or cultural background.

Question 14

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?
    A. Haloperidol (Haldol) to address the negative symptom
    B. Clonazepam (Klonopin) to address the positive symptom
    C. Risperidone (Risperdal) to address the positive symptom
    D. Clozapine (Clozaril) to address the negative symptom

Answer 14

ANS: C
The nurse should expect the physician to order risperidone (Risperdal) to address the positive symptoms of schizophrenia. Risperidone (Risperdal) is an atypical antipsychotic used to reduce positive symptoms, including disturbances in content of thought (delusions), form of thought (neologisms), or sensory perception (hallucinations).

Question 15

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?
A. Tactile hallucinations
B. Tardive dyskinesia
C. Restlessness and muscle rigidity
D. Reports of hearing disturbing voices

Answer 15

ANS: C
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 16

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?
    A. Paranoia, anhedonia, and anergia are positive symptoms of schizophrenia.
    B. Paranoia, neologisms, and echolalia are positive symptoms of schizophrenia.
    C. Paranoia, anergia, and echolalia are negative symptoms of schizophrenia.
    D. Paranoia, flat affect, and anhedonia are negative symptoms of schizophrenia.

Answer 16

ANS: B
The nurse should recognize that positive symptoms of schizophrenia include paranoid delusions, neologisms, and echolalia. The negative symptoms of schizophrenia include flat affect, anhedonia, and anergia. Positive symptoms reflect an excess or distortion of normal functions. Negative symptoms reflect a decrease or loss of normal functions.

Question 17

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?
    A. Neuroleptic malignant syndrome, treated by discontinuing antipsychotic medications
    B. Agranulocytosis, treated by administration of clozapine (Clozaril)
    C. Extrapyramidal symptoms, treated by administration of benztropine (Cogentin)
    D. Tardive dyskinesia, treated by discontinuing antipsychotic medications

Answer 17

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

Question 18

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?
A. Neuroleptic malignant syndrome 
B. Tardive dyskinesia
C. Acute dystonia 
D. Agranulocytosis

Answer 18

ANS: A
Neuroleptic malignant syndrome is a potentially fatal condition characterized by muscle rigidity, fever, altered consciousness, and autonomic instability.

Question 19

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?
A. Respirations of 22 beats/minute
B. Weight gain of 8 pounds in 2 months
C. Temperature of 104F (40C)
D. Excessive salivation

Answer 19

ANS: C
When assessing a client diagnosed with schizophrenia who takes an antipsychotic agent daily, the nurse should immediately address a temperature of 104F (40C). A temperature this high can be a symptom of the rare but life-threatening neuroleptic malignant syndrome.

Question 20

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

Answer 20

ANS: C
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, this side effect places the client at risk for developing orthostatic hypotension.

Question 21

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? 
A. Sore throat, fever, and malaise
B. Akathisia and hypersalivation
C. Akinesia and insomnia
D. Dry mouth and urinary retention

Answer 21

ANS: A
The nurse should intervene immediately if the client experiences a sore throat, fever, and malaise when taking the atypical antipsychotic drug clozapine (Clozaril). Clozapine can have a serious side effect of agranulocytosis, in which a potentially fatal drop in white blood cells can occur. Symptoms of infectious processes would alert the nurse to this potential.

Question 22

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?
A. White blood cell count
B. Liver function studies
C. Creatinine clearance
D. Blood urea nitrogen

Answer 22

ANS: A
The nurse should establish a baseline white blood cell count to evaluate a potentially life-threatening side effect if clozapine (Clozaril) is being considered as a treatment option. Clozapine can have a serious side effect of agranulocytosis, in which a potentially fatal drop in white blood cells can occur.

Question 23

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?
    A. Haloperidol (Haldol), because it is used only in elderly patients
    B. Clozapine (Clozaril), because of a cross-sensitivity to penicillin
    C. Risperidone (Risperdal), because it exacerbates symptoms of depression
    D. Thioridazine (Mellaril), because of cross-sensitivity among phenothiazines

Answer 23

ANS: D
The nurse should know that thioridazine (Mellaril) would be contraindicated because of cross-sensitivity among phenothiazines. Prochlorperazine (Compazine) and thioridazine are both classified as phenothiazines.

Question 24

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?
    A. Altered thought processes R/T hearing voices AEB increased anxiety
    B. Risk for other-directed violence R/T yelling accusations
    C. Social isolation R/T paranoia AEB absence from classes
    D. Risk for self-directed violence R/T depressed mood

Answer 24

ANS: B
The nursing diagnosis that must be prioritized in this situation is risk for other-directed violence R/T yelling accusations. Hearing voices and yelling accusations indicate a potential for violence, and this potential safety issue should be prioritized.

Question 25

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?
    A. Present evidence that supports the reality of the situation
    B. Focus on feelings suggested by the delusion
    C. Address the delusion with logical explanations
    D. Explore reasons why the client has the delusion

Answer 25

ANS: B
The nurse should focus on the client’s feelings rather than attempt to change the client’s delusional thinking by the use of evidence or logical explanations. Delusional thinking is usually fixed, and clients will continue to have the belief in spite of obvious proof that the belief is false or irrational.

Question 26

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?
    A. The client will verbalize the reason the voices make derogatory statements.
    B. The client will not hear auditory hallucinations.
    C. The client will identify events that increase anxiety and illicit hallucinations.
    D. The client will positively integrate the voices into the client’s personality structure.

Answer 26

ANS: C
It is unrealistic to expect the client to completely stop hearing voices. Even when compliant with antipsychotic medications, clients may still hear voices. It would be realistic to expect the client to associate stressful events with an increase in auditory hallucinations. By this recognition the client can anticipate symptoms and initiate appropriate coping skills.

Question 27

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?
    A. The client has developed tolerance to the antipsychotic medication.
    B. The client has not taken the medication with food.
    C. The client has not taken the medication as prescribed.
    D. The client has combined alcohol with the medication.

Answer 27

ANS: C
Altered thinking can affect a client’s insight into the necessity for taking antipsychotic medications consistently. When symptoms are no longer bothersome, clients may stop taking medications that cause disturbing side effects. Clients may miss the connection between taking the medications and an improved symptom profile.

Question 28

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

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

Question 29

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

ANS: A, C, E
The nurse should expect that risperidone (Risperdal) would be effective treatment for 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 30

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

ANS: D, E
Dopamine blockage, an expected action of antipsychotic medications, also results in prolactin elevation. Galactorrhea and gynecomastia are symptoms of prolactin elevation.