Week6Schizophrenia

Question 1

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

B. Note escalating behaviors and intervene immediately

SAFETY!

Question 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

C. How to make eye contact when communicating

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

A 16-year-old client diagnosed with schizophrenia experiences command hallucinations to harm others. The clients 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 childs hallucinations are caused by medication interactions.

C. Your child has too little serotonin in the brain, causing delusions and hallucinations.

D. Your childs abnormal hormonal changes have precipitated auditory hallucinations.

Answer 3

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

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

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

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

The most appropriate response by the nurse is to instruct the parents to 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?

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

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 clients 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

B. The client is expressing a neologism.

The nurse should describe the clients 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

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

B. Delusions of influence

Question 8

A client diagnosed with schizophrenia states, Cant you hear him? Its the devil. Hes telling me Im 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. Im sure the voices sound scary. I dont hear any voices speaking.

D. The devil only talks to people who are receptive to his influence.

Answer 8

C. Im sure the voices sound scary. I dont hear any voices speaking.

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

Question 9

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 clients boundaries.

Answer 9

D. Provide personal space to respect the clients boundaries.

The most appropriate nursing intervention is to provide personal space to respect the clients boundaries. Providing personal space may serve to reduce anxiety and thus reduce the clients risk for violence.

Question 10

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 10

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

The nurse can enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia by being reliable, honest, and consistent during interactions

Question 11

A client diagnosed with schizophrenia states, My psychiatrist is out to get me. Im sad that the voice is telling me to stop him. What symptom is the client exhibiting, and what is the nurses 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 11

C. Command hallucinations; warn the psychiatrist

The nurse should determine that the client is exhibiting command hallucinations. The nurses legal responsibility is to warn the psychiatrist of the potential for harm.

Question 12

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

A. Theres an alien growing in my liver.

B. I see my dead husband everywhere I go.

C. The IRS may audit my taxes.

D. Im not going to eat my food. It smells like brimstone.

Answer 12

A. Theres an alien growing in my liver.

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 persons intelligence or cultural background.

Question 13

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 13

C. Risperidone (Risperdal) to address the positive symptom

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 14

***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 14

C. Restlessness and muscle rigidity

The symptom of tactile hallucinations and reports of hearing disturbing voices would be addressed by an antipsychotic medication such as haloperidol.

Question 15

A nurse is caring for a client who is experiencing a flat affect, paranoia, anhedonia, anergia, neologisms,and echolalia. Which statement correctly differentiates the clients 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 15

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

The nurse should recognize that positive symptoms of schizophrenia include paranoid delusions, neologisms, and echolalia

Question 16

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 16

D. Tardive dyskinesia, treated by discontinuing antipsychotic medications

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 17

client diagnosed with schizophrenia takes an antipsychotic agent daily. Which assessment finding should a nurse immediately report to the clients 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 17

C. Temperature of 104F (40C)

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 18

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 18

A. Sore throat, fever, and malaise

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 19

A client has been recently admitted to an inpatient psychiatric unit. Which intervention should the nurse plan to use to reduce the clients 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 19

B. Focus on feelings suggested by the delusion

The nurse should focus on the clients feelings rather than attempt to change the clients delusional thinking by the use of evidence or logical explanations.

Question 20

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 clients personality structure.

Answer 20

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

It is unrealistic to expect the client to completely stop hearing voices. Even when compliant with antipsychotic medications, clients may still hear voices.

Question 21

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 21

C. The client has not taken the medication as prescribed

Altered thinking can affect a clients 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 22

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 22

ACE

Question 23

A person has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today the person shouts, Theyre all plotting to destroy me. Isnt that true? Select the nurses 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 23

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

Question 24

A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The patient states, I saw two doctors talking in the hall. They were plotting to kill me. The nurse may correctly assess this behavior as:

Answer 24

b. an idea of reference.

Ideas of reference are misinterpretations of the verbalizations or actions of others that give special personal meanings to these behaviors; for example, when seeing two people talking, the individual assumes they are talking about him or her. The other terms do not correspond with the scenario.

Question 25

A patient diagnosed with schizophrenia says, My co-workers are out to get me. I also saw two doctors plotting to kill me. How does this patient perceive the environment?

Answer 25

b. Dangerous

The patient sees the world as hostile and dangerous. This assessment is important because the nurse can be more effective by using empathy to respond to the patient.

Question 26

When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol (Haldol) was prescribed. The patient 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 patient?

Answer 26

a. Sedation and muscle stiffness

Typical antipsychotic drugs often produce sedation and extrapyramidal side effects such as stiffness and gait disturbance, effects the patient might describe as making him or her feel like a robot.

Question 27

Which hallucination necessitates the nurse to implement safety measures? The patient says,

Answer 27

The voices say everyone is trying to kill me.

The correct response indicates the patient is experiencing p

Question 28

A patients care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating?

Answer 28

b. Darting eyes, tilted head, mumbling to self

Question 29

A health care provider considers which antipsychotic medication to prescribe for a patient diagnosed with schizophrenia who has auditory hallucinations and poor social function. The patient is also overweight and hypertensive. Which drug should the nurse advocate?

Answer 29

Aripiprazole (Abilify)

Aripiprazole is a third-generation atypical antipsychotic effective against both positive and negative symptoms of schizophrenia. It causes little or no weight gain and no increase in glucose, high- or low-density lipoprotein cholesterol, or triglycerides, making it a reasonable choice for a patient with obesity or heart disease.

Question 30

A patient diagnosed with schizophrenia tells the nurse, I eat skiller. Tend to end. Easter. It blows away. Get
it? Select the nurses best response.

Answer 30

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

Question 31

A patient diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which patient needs are of priority importance?

Answer 31

Physiological

Physiological needs must be met to preserve life. A patient with waxy flexibility must be fed by hand or tube, toileted, given range-of-motion exercises, and so forth to preserve physiological integrity.

Question 32

A nurse observes a catatonic patient standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon?

Answer 32

Waxy flexibility

Waxy flexibility is the ability to hold distorted postures for extended periods of time, as though the patient were molded in wa

Question 33

A patient is experiencing delusions of persecution about being poisoned. The patient has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the patient?

Answer 33

a. Allowing the patient supervised access to food vending machines

Question 34

Withdrawn patients diagnosed with schizophrenia:

Answer 34

d. avoid relationships because they become anxious with emotional closeness.

Question 35

A newly admitted patient 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 nurses most helpful reply.

Answer 35

c. Ill stay with you. Focus on what we are talking about, not the voices.

Staying with a distraught patient who is hearing voices serves several purposes: ongoing observation, the opportunity to provide reality orientation, a means of helping dismiss the voices, the opportunity of forestalling an action that would result in self-injury, and general support to reduce anxiety.

Question 36

A patient diagnosed with schizophrenia is very disturbed and violent. After several doses of haloperidol (Haldol), the patient is calm. Two hours later the nurse sees the patients head rotated to one side in a stiff position, the lower jaw thrust forward, and drooling. Which problem is most likely?

Answer 36

An acute dystonic reaction

Question 37

A patient took trifluoperazine 30 mg po daily for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patients neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect?

Answer 37

Tardive dyskinesia

Question 38

A nurse sits with a patient diagnosed with schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the nurses best response.

Answer 38

Youre laughing. Tell me whats happening.

Question 39

The nurse assesses a patient diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia?

Answer 39

Poor personal hygiene

Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning.

Question 40

What assessment findings mark the prodromal stage of schizophrenia?

Answer 40

Withdrawal, misinterpreting, poor concentration, and preoccupation with religion

Question 41

A patient 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?

Answer 41

Paranoia

The patients unrealistic fear of harm indicates paranoia.

Question 42

A patient diagnosed with schizophrenia begins a new prescription for lurasidone HCL (Latuda). The patien is 56 and currently weighs 204 lbs. Which topic is most important for the nurse to include in the teaching plan related to this medication?

Answer 42

Weight management strategies

(Latuda) is a second-generation antipsychotic medication. The incidence of weight gain, diabetes, and high cholesterol is high with this medication. The patient is overweight now, so weight management will be especially important

Question 43

A patient diagnosed with schizophrenia says, Its beat. Time to eat. No room for the cat. What type of verbalization is evident?

Answer 43

Associative looseness

Looseness of association refers to jumbled thoughts incoherently expressed to the listener. Neologisms are newly coined words

Question 44

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

Answer 44

Psychoeducational

Question 45

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

Answer 45

relapse

Signs of potential relapse include feeling tense, difficulty concentrating, trouble sleeping, increased withdrawal, and increased bizarre or magical thinking.

Question 46

A patient diagnosed with schizophrenia begins to talks about macnabs hiding in the warehouse at work. The term macnabs should be documented as:

Answer 46

neologism

A neologism is a newly coined word having special meaning to the patient

Question 47

A patient 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:

Answer 47

maintain a normal social interaction distance from the patient.

Question 48

A patient diagnosed with schizophrenia and auditory hallucinations anxiously tells the nurse, The voice is telling me to do things. Select the nurses priority assessment question.

Answer 48

What is the voice telling you to do?

Learning what a command hallucination is telling the patient to do is important because the command often places the patient or others at risk for harm. Command hallucinations can be terrifying and may pose a psychiatric emergency.

Question 49

A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 1030. By 1200, the patient has difficulty swallowing and is drooling. By 1600, vital signs are 102.8 F; pulse 110; respirations 26; 150/90. The patient is diaphoretic. Select the nurses best analysis and action.

Answer 49

Neuroleptic malignant syndrome; notify health care provider stat.

Taking an antipsychotic medication coupled with the presence of extrapyramidal symptoms, such as severe muscle stiffness and difficulty swallowing, hyperpyrexia, and autonomic symptoms (pulse elevation), suggest neuroleptic malignant syndrome, a medical emergency.

Question 50

A nurse asks a patient diagnosed with schizophrenia, What is meant by the old saying You cant judge a book by looking at the cover.? Which response by the patient indicates concrete thinking?

Answer 50

The table of contents tells what a book is about.

Question 51

The nurse is developing a plan for psychoeducational sessions for several adults diagnosed with schizophrenia. Which goal is best for this group? Members will:

Answer 51

d. demonstrate improved social skills.

Improved social skills help patients maintain relationships with others. These relationships are important to management of the disorder.

Question 52

A client says, Facebook has a new tracking capacity. If I use the Internet, Homeland Security will detain me as a terrorist. Select the nurses best initial action.

Answer 52

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

Question 53

Which finding constitutes a negative symptom associated with schizophrenia?

Answer 53

Poverty of thought

Question 54

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

Answer 54

Word salad

Word salad (schizophasia) is a jumble of words that is meaningless to the listener and perhaps to the speaker as well, because of an extreme level of disorganization.