EAQ: Psychosis

Which response by the nurse would be therapeutic to a client who dose not want to go to occupational therapy?

"Tell me what concerns you about going to occupational therapy."

Which statement by the nurse reflects understanding of the characteristics of schizophrenia?

"Delusions are fixed ideas that are not based in reality."

A client experiencing auditory hallucinations ask a nurse, "Can you hear the voices?" Which response by the nurse is appropriate?

"I don't hear the voices, but I believe that you can hear them."

A nurse is counseling the caregiver of a client with a personality disorder about antipsychotic medication. Which statement made by the caregiver during evaluation indicates a need for further teaching?

"I should cut down on the salt content in her food." Rationale: Antipsychotic drugs can have anticholinergic effects such as postural hypotension. Therefore, the client should increase her salt intake and be careful to get up slowly from sitting or lying position.

Which statement by a client scheduled to undergo electroconvulsive therapy (ECT) indicates a need for further teaching?

"I should not void for 4 hours before the treatment." Rationale: ECT is used to treat mania, depression, and schizoaffective disorders that do not respond to other treatments. The client who is scheduled for ECT should be instructed to void just before the treatment.

A client with schizophrenia is admitted to a psychiatric unit. The client is talking while walking in the hall, is unkempt, and obviously has not washed in several days. Which response by the nurse is most likely to encourage this client to shower?

"I'll help you take your shower now." Rationale: The client is displaying a self-care deficit; stating the intention of helping the client shower is direct, does not require the client to make a decision, provides help, and meets the client's physiologic and psychological needs.

A confused, hallucinating client says, "My arms are turning to stone." Which response will the nurse make?

"It can be frightening to feel that way." Rationale: Depersonalization communication is the result of a high anxiety level; projecting empathy to the client by acknowledging frightening feelings will facilitate explorations of concerns.

Which client statement supports the diagnosis of somatic delusions?

"My heart stopped beating 3 days ago, and now my lungs are rotting away." Rationale: A somatic delusion is a belief that the body is changing or behaving in an unusual way.

Which statement supports the nurse's conclusion that a client is experiencing a somatic delusion?

"My stomach has disintegrated."

A nurse is writing a plan of care in the medical record of a paranoid male client who has unjustifiably accused his wife of having many extramarital affairs. Which outcome statement is considered intermediate?

"The client will develop feelings of self-worth." Rationale: Helping the client develop feelings of self-worth will reduce the client's need to use pathologic defenses.

A client with schizophrenia has reported ongoing hallucinations that say "I am a bad person." After confirming with the client that these are not command hallucinations, which response by the nurse is most appropriate?

"Try to ignore the voices." Rationale: Clients can sometimes learn to push auditory hallucinations aside, particularly within the framework of a trusting relationship; it may provide the client with a sense of power to manage the voices.

A client diagnosed with schizophrenia, paranoid type, states to the nurse, "I know they're spying on me in here, too. I'm not safe anywhere." Which response is therapeutic?

"You don't feel safe anywhere, not even in the hospital?" Rationale: Rephrasing facilitates further communication, helps the nurse express understanding, and does not belittle the client's feelings.

A client diagnosed with chronic schizophrenia, paranoid type, shows a nurse a small, soft stuffed animal. The client then hides it, yelling, "Don't take it away! It's the only thing which protects me from evil forces." Which response is appropriate?

"You may keep it because I know it's important to you."

Which response by the nurse is best when a client with the diagnosis of paranoid schizophrenia continues to say, "They're trying to kill me. They all are"?

"You're having very frightening thoughts." Rationale: The observation that the client is experiencing frightening thoughts is a reflection of the client's feelings; it leaves the line of communication open.

A client with bipolar disorder, manic episode, is prescribed a regimen of an antipsychotic agent and lithium carbonate. Which action of the antipsychotic will the nurse explain as the rationale for this regimen?

Acts to calm the client while allowing time for the lithium to reach a therapeutic level Rationale: Antipsychotics usually are prescribed to calm and sedate agitated clients during the 3 week period it takes for the lithium to become effective.

Which characteristic accurately describes delusions according to the psychodynamic theory?

A defense against anxiety Rationale: Delusions are a way the unconscious defends the individual from real or imagined threats.

Which information would the nurse distinguish as important when preparing to give an intramuscular injection to an 8 year old child for an acute episode of psychosis?

A deltoid injection in a child should be given in the thickest part of the muscle.

Which clinical manifestation best indicates improvement in the mental status of a client diagnosed with schizophrenia, paranoid type?

Ability to function effectively in activities of daily living Rationale: A person who can handle the activities of daily living and function in society is considered mentally stable.

Which nursing approach should be implemented first when caring for a client who presents a self accusatory and guilt-ridden?

Accept the client's statements as the client's beliefs. Rationale: The nurse must accept the clients statement and beliefs as real to the client to develop trust and move toward a therapeutic relationships.

A hospitalized psychiatric client with the diagnosis of histrionic personality disorder demands a sleeping pill before going to bed. After being refused the sleeping pill, the client throws a book at the nurse. Which behavior identifies the client's response?

Acting out

A sudden terrorist act causes the deaths of thousands of adults and children, negatively affecting families, friends, communities, and the nation. Which category describes this type of crisis?

Adventitious Rationale: An adventitious crisis is a crisis or disaster that is unplanned and accidental; its subcategories include national disasters and crimes of violence.

At which times in the daily routine do clients tend to hallucinate more vividly?

After going to bed Rationale: Auditory hallucinations are most troublesome when environmental stimuli are diminished and there are few competing distractions. Before meals, during group activities, and during television watching are all times of relatively high, competing environmental stimuli.

Which side effect would the nurse suspect if a client prescribed haloperidol for 2 weeks reports, "I just can't sit still, and I feel jittery"?

Akathisia Rationale: Akathisia, a side effect of haloperidol, develops early in therapy and is characterized by restlessness and agitation.

The nurse is working with a group of clients in a mental health facility. Which condition will lead the nurse to assess for suicide risk? (Select all that apply.) Anxiety Alcohol abuse Schizophrenia Bipolar disorder Attention deficit disorder

Alcohol abuse Schizophrenia Bipolar disorder Rationale: Certain mental health disorders increase a person's risk for suicide. These include alcohol abuse, schizophrenia, and bipolar disorder.

Which action would the nurse take when a client taking lithium for bipolar disorder states, "I didn't see the need to refill the prescription"? (select all that apply.) Explain the action of lithium Assess the client's knowledge of bipolar disorder Ask the client what side effects are being experienced Explore whether the client can afford to buy the medicaiton Discuss maintaining blood levels of the drug y taking it regularly Advise of potential complications of uncontrolled bipolar disorder

All of the above

Which intervention would the nurse implement as directed when finding poor skin turgor and scanty urine output on assessment of a client experiencing a psychotic episode? Turn at least every 2 hours Initiate input and output recording Watch urine output closely Perform neurologic assessment every 4 hours Encourage oral fluids in small amounts Give intravenous solution at 125 mL per hour as prescribed

All of the above

Which action should be implemented by the nurse when a client refuses to remove dirty clothing during admission to the behavioral health unit?

Allowing the client to undress when ready to help maintain identity

Which basic principle represents Alcoholics Anonymous (AA)?

Amends must be made to each person who has been harmed. Rationale: The eighth step of the 12 steps of AA is "made a list of all person we had harmed, and became willing to make amends to them all."

A client with schizophrenia is unable to feel happiness and joy. Which symptom does this describe?

Anhedonia

Which symptom is expected when caring for a client with the diagnosis of major depression? (Select all that apply.) Apathy Insomnia without fatigue Mood swings with manic episodes Guilt feelings Sleep disturbances

Apathy Guilt feelings Sleep disturbances

A nurse is assessing a client with chronic schizophrenia. Which effect will the client likely exhibit? (Select all that apply.) Apathy Hostility Flatness Sadness Happiness Depression

Apathy Flatness Rationale: Apathy is common among people with chronic schizophrenia because negative symptoms are more apparent. Flatness, with few extremes of emotion, is common among people with chronic schizophrenia because negative symptoms are more apparent.

Which response by the nurse demonstrates an understanding of a client's hallucinating behavior?

Asking, "what are the voices telling you to do?" Rationale: A hallucination involves false perceptions of sensory stimuli that may be visual, auditory, tactile, or olfactory. Hearing voices is a common hallucination, and it is appropriate for the nurse to clarify exactly what the client is hearing.

Which type of hallucination is most commonly experienced?

Auditory

Which is the primary basis for the development of schizophrenia?

Biological perspective Rationale: Biological factors, including genetics, neuroanatomy, and abnormal neurotransmitter-endocrine interactions, prevail as the origin of schizophrenia as a result of studies conducted during the 20th century.

For which diagnosis is the establishment of a psychiatric advance directive (PAD) beneficial? (Select all that apply.) Bipolar disease Paranoid schizophrenia Illness anxiety disorder Obsessive-compulsive disorder Narcissistic personality disorder

Bipolar disease Paranoid schizophrenia Rationale: Individuals with manic-depressive illness may have psychotic episodes during which they are unable to perceive and response to reality appropriately; mania diminishes judgment and insight, which in turn reduces a client's ability to make decisions. Individuals with paranoid schizophrenia may have psychotic episodes during which they are unable to perceive and response to reality appropriately; paranoia makes a client overly suspicious, which diminished judgment and insight.

Which action of neuroleptic drugs prescribed for schizophrenic clients promotes mental health?

Blocking access to dopamine receptors at the postsynaptic receptor site Rationale: Neuroleptics block access to dopamine receptors, rather than inhibiting enzymes, at postsynaptic sites. They increase, not decrease, serotonin at postsynaptic sites.

Which vital sign is most important to monitor in a client taking monoamine oxidase inhibitors (MAOIs)?

Blood pressure Rationale: Blood pressure is the most important vital signs to assess and monitor while a client is taking MAOIs. Orthostatic hypotension is the most common adverse effect. Hypertensive crisis is a serious adverse effect of MAOIs. Other side effects include neurologic, sensory, gastrointestinal, and genitourinary effects.

Which information should be taken into consideration by the nurse when caring for adolescent clients who attempt suicide?

Boys are more likely to use lethal methods than girls. Rationale: The finding that boys are more likely to use lethal methods than girls is supported by research; girls account for 90% of suicide attempts, but boys are three times more successful because of the methods they use.

Which condition of electroconvulsive therapy (ECT) primary used to treat?

Clinical depression Rationale: ECT is used to treat clinical depression in clients who do not respond well to a trial of psychotropic medications or are so severely depressed that immediate intervention is needed.

Which clinical findings indicate positive signs and symptoms of schizophrenia?

Hyperactivity, auditory hallucinations, loose associations Rationale: Positive symptoms reflect a distortion or excess of normal function.

Which obligation does not apply to the mental health care probider?

Change the client. Rationale: Changing the client is not an obligation of the healthcare provider; the client is accepted as a person who is capable of change.

Which drug will cause a heightened skin reaction to sunlight?

Chlorpromazine

While caring for a client with schizophrenia, a nurse understands that psychotherapy is against the client's religious beliefs. To which religious community does the client likely belong?

Christian Science Rationale: The Christian Science community is against certain therapies, including psychotherapy. The Mormon, Disciples of Christ, and Pentecostal communities do not prohibit psychotherapy.

Which behavior correctly describes what a client is experiencing when making the statement, "I hear my deceased son telling me to come over to the other side"?

Command hallucination Rationale: Command hallucination are auditory hallucinations that give verbal messages to do harm either to the self or others' giving an identity to the hallucinated voices increases the risk of compliance.

A client has been prescribed chlorpromazine for the management of positive symptoms of schizophrenia. Which action will the nurse take if the client reports difficulty sustaining an erection?

Consult with his provider regarding alternative medication therapies. Rationale: Although erectile dysfunction can result from conventional antipsychotic medication therapy, the provider is often able to prescribe an alternative medication that will help manage symptoms of schizophrenia but is less likely to cause erectile dysfunction.

A nurse greets a client who has been experiencing auditory hallucinations and delusions of persecution by saying, "Good evening; how are you?" The client responds, "He doesn't feel well." Which phenomenon does this response represent?

Dissociation Rationale: Speaking in the third person reflects poor ego boundaries and dissociation from the real self.

A client insists he is the commander of an alien spaceship, despite repeated nursing interventions to improve reality orientation. Which symptom does this represent?

Delusion Rationale: A delusion is a fixed, false belief. An illusion is a false sense interpretation of an external stimulus. Confabulation is the client's attempt to fill gaps in memory with imaginary events. A hallucination is a false sensory perception with no external stimulus.

A client on the psychiatric unit tells the nurse, "I'm a movie star, and the other clients are my audience." Which conclusion is appropriate for the nurse to document about what the client is experiencing?

Delusion of grandeur Rationale: A delusion of grandeur is a fixed false belief that the person is a powerful, important person.

In her eighth month of pregnancy, a 24 year old client is brought to the hospital by the police, who were called when she barricaded herself in a ladies' restroom of a restaurant. During admission the client shouts, "Don't come near me! My stomach is filled with bomb, and i'll blow up this place if anyone comes near me." Which assessment will the nurse document regarding the behavior of this client?

Delusional thinking

Which problem is common to assess in a client diagnosed with schizophrenia?

Disordered thinking Rationale: The individual with schizophrenia has neurobiological changes that cause disorders in thinking and perceiving reality.

A client's parents ask about the treatment of their child who has a recent diagnosis of schizophrenia. Which information should the nurse consider before responding?

Drug therapy, although it does not eliminate the underlying problem, reduces the symptoms of acute schizophrenia. Rationale: Psychoactive drugs have been shown to be capable of interrupting the acute psychiatric process, making the client more amenable to other therapies.

Which second-generation antidepressant can worsen uncontrolled angle-closure glaucoma?

Duloxetine Rationale: Duloxetine can worsen uncontrolled angle-closure glaucoma. Trazodone is contraindicated in clients with a known drug allergy. Bupropion is contraindicated for clients with seizures. Mirtazapine is contraindicated in cases of known drug allergy and concurrent use of Monoamine oxidase inhibitors.

A client is admitted to the acute care psychiatric unit with a diagnosis of panic disorder with agoraphobia. Which intervention should the nurse implement during the initial assessment phase?

Ease the client's anxiety so further interviewing may be done Rationale: The client will be unable to concentrate or focus on the interview if anxiety is not reduced.

Which response by the nurse is most therapeutic when a client on a behavioral health unit continually talks about delusional topics?

Encourage the client to focus on reality issues. Rationale: Discussing reality-based issues helps decrease delusional and hallucinatory activity by reducing feelings of isolation and competition for sensory awareness.

A client is being admitted to the psychiatric unit. Which clinical manifestation does the nurse expect to assess in a client with a diagnosis of undifferentiated schizophrenia? (Select all that apply.) Excited behaviors Loose associations Inappropriate affect Feelings of depression Hypervigilant behavior

Excited behaviors Loose associations Inappropriate affect

Which symptom or symptoms relate to neuroleptic malignant syndrome (NMS)?

Fever, confusion, muscle rigidity, tremor, and incontinence Rationale: NMS is a serious and potentially fatal side effect of antipsychotics. Symptoms include unstable vital signs, fever, confusion, muscle rigidity, tremor, and incontinence.

When a client is breastfeeding, which medication can place the infant at risk?

Fluoxetine Rationale: Fluoxetine can be passed to infants through breastfeeding. The medication's presence in breast milk can cause colic and inadequate weight gain.

Which prescription medication may be best for a client diagnosed with schizophrenia who forgets to take medications?

Fluphenazine Rationale: Fluphenazine can be given intramuscularly every 2 to 3 weeks to clients who are unreliable about taking oral medications; it allows them to live in the community while keeping disorder under control

Which selective serotonin reuptake inhibitor (SSRI) will the nurse anticiapte that the health care provider may prescribe to a client admitted with a diagnosis of obsessive-compulsive disorder?

Fluvoxamine

Which herb may improve memory and boost energy?

Ginkgo Rationale: Ginkgo and ginseng improve memory and boost energy. Gotu kola is useful in treating anxiety. Rosemary and cedarwood may help relieve stress and achieve mental balance.

Which activity is most therapeutic for a withdrawn client exhibiting hallucinations?

Go for a walk with the nurse. Rationale: Going for a walk with the nurse facilitates one-on-one interaction and the development of a trusting relationship.

Which relaxation technique is the nurse using when advising a client with anxiety to focus on a positive scene?

Guided imagery Rationale: Guided imager is the process of using pleasant images to help reduce stress and anxiety levels.

Which antipsychotic drug would be contraindicated for a 60 year old client diagnosed with dementia? (Select all that apply.) Quetiapine Haloperidol Aripiprazole Risperidone Chlorpromazine

Halooeridol Chlorpromazine Rationale: First-generation antipsychotic drugs such as haloperidol and chlorpromazine are contraindicated because they may increase the risk for mortality when used to treat dementia-related psychosis in older adult clients.

A client with the diagnosis of schizophrenia refuses to eat meals. Which nursing action is most beneficial for this client?

Have a staff member sit with the client in a quiet area during mealtimes. Rationale: By having a staff member sit with the client during mealtimes, the nurse can evaluate how much the client is eating; this encourages the client to eat and begins the construction of a trusting relationship.

Which task should be achieved by 20 years of age, according to Erikson's developmental psychosocial theory?

Having coherent sense of self and plans for self-actualization Rationale: Having coherent sense of self is a task of adolescence. By age 20 this goal should be achieved. Young adults, ages 18 to 35, should still be developing meaningful relationships and establishing themselves in careers. The stage of adulthood is concerned with productivity, nurture, and support of the next generation. From age 65 to death, an individual should experience a feeling of the worth of their life.

Which initial nursing intervention is a priority for a client admitted to a behavioral health unit with the diagnosis of schizoid personality disorder?

Help the client learn to trust the staff through selected experiences.

Which description is documented by the nurse when the client says, "That man on the television is talking only to me?"

Idea of reference Rationale: An idea of reference, also called a delusion of reference, is a fixed, false personal belief that public events and people are connected directly to the client.

A young client is admitted to the hospital with a diagnosis of acute schizophrenia. The family reports that one day the client looked at a linen sheet on a clotheslines and thought it was a ghost. Which is the most appropriate conclusion to make about what the client was experiencing?

Illusion Rationale: An illusion is a misinterpretation of an actual sensory stimulus.

Which clinical finding will the nurse expect in a client with catatonic schizophrenia?

Immobile posturing Rationale: Clients with catatonic schizophrenia exhibit rigidity and posturing behaviors.

which is the priority short-term outcome of care for a client with schizophrenia who is admitted in a vegetative catatonic state?

Ingesting adequate fluid and food with assistance Rationale: A client in a catatonic or vegetative state may not eat or drink without assistance; fluids and foods are basic physiologic needs that are necessary to prevent malnutrition and starvation; therefore, the intake and adequate fluid and food is a priority short-term goal.

A client who has been admitted with a diagnosis of schizophrenia says to the nurse, "Yes it's March. March is Little Women. That's literal, you know." Which term correctly identifies what these statements illustrate?

Loosening of associations

Which symptom is classified as negative symptoms of schizophrenia? (Select all that apply.) Lack of energy Poor grooming Illogical speech Ideas of reference Agitatated behavior

Lack of energy Poor grooming

A nurse is assessing a middle-aged client whose children have left home in search of work. Which family life cycle stage is the client going through?

Launching children and moving on Rationale: The client is adjusting to a reduction in family size after the adult children have left home in search of work. The client is going through the launching children and moving on stage of the family life cycle.

Which action will best limit confusion resulting from sleep deprivation in a client diagnosed with dementia?

Leaving a dim light on the client's room at night Rationale: A small light in the room may prevent misinterpretation of shadows, which can heighten fear and alter the client's perception of the environment.

Which speech pattern describes the statements made by a client with schizophrenia who states, "I've been here 5 days. There are 5 players on a basketball team. I like to play the piano"?

Loose association Rationale: These ideas are not well connected, and there is no clear train of thought which is an example of loose association.

A nurse is caring for an adolescent client with the diagnosis of schizophrenia, undifferentiated type. Which signs and symptoms should the nurse expect the client to experience?

Loosened associations and hallucinations Rationale: Loosened associations and hallucinations are the primary behaviors associated with a thought disorder such as schizophrenia.

An older client, with a history of multiple admissions for heart failure, is returned to the hospital by an adult child. After admission for observation to the coronary care unit, the client calmly states, "I know I'm sick, but I really can take care of myself at home." Which result will the nurse conclude the client is attempting to achieve?

Maintain independence

Which goal of medication therapy will the nurse discuss with family about a client with schizophrenia who is started on an antipsychotic/neuroleptic medication?

Making the client better able to participate in psychotherapy. Rationale: Antipsychotic/neuroleptic medications help control anxiety, improve cognition, and decrease acting-out behavior, rendering the client better able to participate in therapy.

Which information regarding intramuscular injection would the nurse need to recall when caring for a client with schizophrenia who is prescribed reserpine?

Medication is injected in a slow, continuous motion. Rationale: Injecting medication with a slow, continuous motion is less painful because the tissue has time to absorb the medication.

A nurse is assigned to lead a relaxation group. Which technique would the nurse incorporate? (Select all that apply.) Mediation Mental imagery Token economy Operant conditioning Deep-breathing exercises

Meditation Mental imagery Deep-breathing exercises Rationale: Meditation lowers heart and blood pressure rates, decreases levels of adrenal corticosteroids, improves mental alertness, and increases a sense of calmness and peace. Mental imagery is the internal experience of memories, dreams, fantasies, and visions that serves as a bridge connecting the body, mind, and spirit; its distractive ability decreases adrenal corticosteroids, promotes muscle relaxation, and increases a sense of calmness and peace. Deep breathing increases oxygenation and releases tension in the muscles of the neck, shoulders, and torso.

The health care provider has discontinued clozapine for a client recovering from a psychotic episode. Which outcome would the nurse expect to be included in the nursing plan of care?

Monitor white blood cell (WBC) counts weekly for at least 4 weeks. Rationale: WBC counts must be monitored weekly for at least 4 weeks after the discontinuation of clozapine because of the high risk for agranulocytosis

Which client behaviors indicate the presence of akathisia?

Motor restlessness, foot tapping, and pacing

Which nursing intervention should be implemented when a client is agitated, pacing, and verbalizing the belief that others are out to cause them harm?

Move the client to a quiet place on the unit. Rationale: A client losing control feels frightened and threatened; this client needs external controls and a reduction in external stimuli.

Which assessment finding supports the diagnosis of neuroleptic malignant syndrome (NMS) in a client with schizophrenia being treated with haloperiodol? (select all that apply.) Muscle stiffness Sweating Tongue rolling Temperature 105°F (41°C) Arching of the trunk

Muscle stiffness Sweating Temperature 105°8F (41°C)

A client with schizophrenia repeatedly says to the nurse, "No moley, jandu!" Which behavior is the client exhibiting?

Neologism Rationale: Neologism are words that are invented and understood only by the person using them.

The nurse is administering a prescribed antidepressant medication to a client in an inpatient mental health facility. Which action would the nurse perform to ensure the client is not stashing doses of medicaiton?

Observe the client swallowing the medication

An older adult client is talking to the nurse about their Vietnam experiences and shares that they still have flashbacks. While assessing the client, the nurse notes that they are jumpy and exhibits startle reactions and poor concentration. Which mental health disorder is associated with these symptoms?

Post-traumatic stress disorder (PTSD)

What are the levels of prevention?

Primary Prevention—intervening before health effects occur, through. Secondary Prevention—screening to identify diseases in the earliest. Tertiary Prevention—managing disease post diagnosis to slow or stop

Which concept refers to respecting the right of others?

Open-mindedness

Which drug category includes heroin?

Opioids

Which subtype of schizophrenia may have a good prognosis with treatment?

Paranoid

Which action address the potential for fluid overload if a client with schizophrenia is receiving intravenous (IV) fluids after being dehydrated?

Perform auscultation of lungs.

A client with schizophrenia is demonstrating waxy flexibility. Which intervention is the best way to manage the possible outcome of this behavior?

Performing passive range-of-motion exercises three times a day for effective joint health Rationale: Waxy flexibility is an excessive and extended maintenance of posture that can lead to a variety of problems, including joint trauma. Passive range-of-motion exercises focus on the effective management of joint mechanics.

Which medication is likely to be responsible for development of extrapyramidal symptoms? Clozapine Olanzapine Perphanazine Fluphenazine Trifluoperazine

Perphanazine Fluphenazine Trifluoperazine

A young adult client is admitted to the hospital with a diagnosis of schizophrenia, paranoid type. The client has been saying, "The voices in heaven are telling me to come home to God." Which client problem should be the initial focus of care?

Possibility of self-harm Rationale: Client safety always is the priority over any other client need, and command hallucinations increase the risk of injury.

Which type of room is the most appropriate to prepare for a client with a diagnosis of bipolar disorder, manic phase, being admitted to a behavior health unit?

Private Rationale: The client who is manic needs a nonstimulating environment, so a private room is needed

Which need will the nurse focus on, considering Erikson's psychosocial developmental tasks, when planning care for a middle aged adult?

Productivity Rationale: a psychosocial tasks for middle adulthood according to Erickson is generativity; this task is concerned with the sense of productivity and accomplishment.

Which defense mechanism is demonstrated when a client is actively hallucinating and worried about being stalked by a terrorist group?

Projection

Which medication is commonly prescribed for schizophrenia?

Promazine

Which would be the nurse's priority when caring for a schizophrenic client exhibiting signs of impaired judgment, paranoid, and agitation?

Protecting other clients

A man is found to have paranoid schizophrenia, and the healthcare provider prescribes a typical antipsychotic medication. After taking the medication for one month, the client comes to the clinic and says, "I feel stiff, my hands shake and I started drooling." Which extrapyramidal side effect does the nurse conclude has developed?

Pseudoparkinsonism Rationale: Pseudoparkinsonism (drug-induced parkinsonism) has adaptations to similar to those of Parkinson disease. Pseudoparkinsonism, an extrapyramidal side effect of typical antipsychotics, can occur any time after initiation of therapy.

Which therapy is long-term and intense and enables a client to bring unconscious thoughts to surface?

Psychoanalysis

Which service type is the nurse using when coordinating multidisciplinary services to help client gain skills needed to carry out activities of daily living as actively and independently as possible?

Psychosocial rehabilitation

Which action will the nurse take after a client with the diagnosis of schizophrenia talks to the nurse about being controlled by others?

React to the feeling tone of the client's delusion

Which action by the nurse would decrease the risk for injury for a child with oppositional defiant disorder?

Redirect anger in other ways Rationale: the nurse would work with the child to learn how to take control of, take responsibility for, and redirect angry outburts.

Which statement regarding alogia is true?

Reduced content of speech

Which priority intervention would the nurse implement for a client with postpartum psychosis? Teaching the client about normal newborn care Ensuring adequate bonding time with the infant Giving the client time and space to express her feelings Referring the client to a psychiatric health care provider as prescribed

Referring the client to a psychiatric health care provider as prescribed

Which defense mechanism should the nurse anticipate that a client with the diagnosis of schizophrenia, undifferentiated type, will most often exhibit?

Regression

Which action should the nurse implement when a client who is hallucinating reports, "I'm hearing voices that are saying bad things about me"?

Replying"I'll stay with you for a while because you seem frightened."

Which subtype of schizophrenia has a poor prognosis? (select all that apply.) Residual Paranoid Catatonic Disorganzied Undifferentiated

Residual Disorganized

Which process is the nurse performing when referring a client with postpartum depression to a women's health center for continued treatment?

Resource linkage Rationale: Resource linkage is the process of matching the client's needs to the most appropriate services with the additional component of periodic monitoring.

Which intervention is a major component of behavior modification?

Rewarding positive behavior

Which condition is a physical condition in an alcoholic client?

Risk for poisoning

Which response is most therapeutic when a nurse enters a room to administer an oral medication to an agitated and angry client with schizophrenia, paranoid type, and the client shouts, "Get out of here!"?

Say, "I'll be back in a few minutes so we can talk." Rationale: Saying "I'll be back in a few minutes so we can talk" allows the angry client time to regain self-control; announcing a plan to return will ease fears of abandonment or retribution.

Which mental disorder is considered a though process disorder?

Schizophrenia

An adult with the diagnosis of schizophrenia is admitted to the psychiatric hospital. The client is ungroomed, appears to be hearing voices, is withdrawn, and has not spoken to anyone for several days. Which intervention with the nurse implement during the first few hospital days?

Seek out the client frequently to spend short periods together. Rationale: Seeking out the client frequently to spend short periods together will help the nurse establish trust without unduly increasing anxiety.

Which action would the nurse take when, in addition to hallucinating, a client yells and curses throughout the day?

Seek to understand what the behavior means to the client. Rationale: All behavior has meaning; before planning intervention, the nurse must try to understand what the behavior means to the client.

Which intervention would be appropriate for a client who believes their food is poisoned?

Serve each food item in single-serving, disposable containers.

Which basis would the primary health care provider use to prescribe a neuroleptic drug to a client diagnosed with schizophrenia?

Side effects Rationale: First-generation antipsychotic drugs are also known as neuroleptics. The selection of these drugs is primarily based on side effects rather than therapeutic effects.

An acutely ill client with the diagnosis of schizophrenia has just been admitted to the mental health unit. Which initial nursing intervention is the most therapeutic?

Spend time with the client to build trust and demonstrate acceptance.

Which drug category represents cocaine?

Stimulant

Which client characteristic is an initial concern for the nurse when admitting a client with the diagnosis of paranoid schizophrenia?

Suspicious thoughts Rationale: The nurse must consider the client's suspicious thoughts and feelings and work to establish basic trust with the client upon admission to promote a therapeutic milieu.

Which extrapyramidal side effect of antipsychotic medications may be irreversible?

Tardive dyskinesia Rationale: Tardive dyskinesia, an extrapyramidal response characterized by vermicular movements and protrusion of the tongue, chewing and puckering movements of the mouth, and puffing of the cheeks, is often irreversible, even when the antipsychotic medication is withdrawn.

When a disturbed client who has a history of using neologisms says to the nurse, "My lacket huss kelong mon," which response will the nurse use?

Telling the client that these words cannot be understood Rationale: Telling the client that these words are not understood is a simple statement that provides feedback and points out reality.

Which observation would the nurse document when a client is using confabulation?

The client uses imagination to fill in memory gaps. Rationale: Confabulation is a defense mechanism used by people experiencing memory deficits and uses imagination to fill in memory gaps.

Which characteristic is the most important tool a nurse brings to the therapeutic nurse-client relationship?

The self and a desire to help

Which is correct about the antianxiety agent buspirone?

Therapeutic effects are not seen for 3 to 6 weeks.

A teenager who attempted suicide is admitted to a psychiatric center for care. On assessment, the teenager tells the nurse the reason was the end of a romantic relationship. Which member of the rehabilitation care team may play a major role in providing care to this teenager?

Therapeutic recreation therapist Rationale: The teenager who attempted suicide due to a breakup may be suffering from depression. The psychiatrist may ask the therapeutic recreation therapist to help diver the teenager's thinking by promoting the client's interest in activities.

Which drug is considered a neuroleptic? (Select all that apply.) Asenapine Lurasidone Aripiprazole Thioridazine Chlorpromazine

Thioridazine Chlorpromazine Rationale: First-generation antipsychotic drugs are also known as neuroleptics. Thioridazine and chlorpromazine are neuroleptics. Asenapine, lurasidone, and aripiprazole are second-generation drugs, which are considered atypical antipsychotic drugs.

In which type of delusion does a client believe that thoughts are being removed from his or her mind?

Thought withdrawal

Clients who have severe psychiatric disorders are prescribed antipsychotic medication for which reason?

To reduce positive symptoms of psychosis

An administrative assistant in a home health agency gossips about coworkers and the writes them notes to tell them how valuable they are to organization and how much they like working with them. Which defense mechanism is the administrative assistant using?

Undoing Rationale: Undoing is atonement for an attempt to dissipate unacceptable acts or wishes.

Which intervention would the nurse implement to decrease injection discomfort for a client prescribed paliperidone for schizophrenia? (Select all that apply.) Apply eutectic mixture of local anesthetics (EMLA) cream after injection Use the shortest needle that is appropriate Use the Z-track method for all irritation medicaitons Encourage the client to rest the muscle after the injection Ask the client to assume a supine position with feet turned inward Press down with the thumb over the injection site for 10 minutes to numb it

Use the Z-track method for all irritation medicaitons. Rationale: Using the Z-track method for all irritation medications will decrease injection discomfort by keeping the irritant below the surgace of the skin where pain receptors are located.

Which long-term outcome is appropriate for a client experiencing a major depressive episode?

Verbalizing realistic perceptions of self and others Rationale: A major part of depression involves an inability to accept the self as is, which leads to making demands on others to meet unrealistic needs.

While watching television in the dayroom a client who has demonstrated withdrawn, regressed behavior suddenly screams, bursts into tears, and runs from the room to the far end of the hallways. Which intervention by the nurse should be implemented?

Walk to the end of the hallway where the client is standing. Rationale: Walk to the end of the hallway where the client is standing lets the client know that the nurse is available. It also demonstrates an acceptance of the client.

Which alcoholism-associated disorder causes damage to the client's temporal lobes of the brain?

Wernickle encephalopathy

Which medication is appropriate for treating symptoms of schizophrenia?

Ziprasidone Rationale: Ziprasidone is a neuroleptic, which will reduce psychosis by affecting the action of both dopamine and serotonin.