Nurse Lab 10

A client with catatonic schizophrenia is mute, can't perform activities of daily living, and stares out the window for hours. What is the nurse's first priority? A. Assist the client with feeding. B. Assist the client with showering C. Reassure the client about safety D. Encourage socialization with peers

A. Assist the client with feeding

A Schizophrenic client states, "I hear the voice of King Tut." Which response by the nurse would be the most therapeutic? A. I don't hear the voice, but i know you hear what sounds like a voice. B. You shouldn't focus on that voice C. Don't worry about the voices as it doesn't belong to anyone real D. Kind Tut has been dead for years

A. I don't hear the voice, but i know you hear what sounds like a voice.

Which of the following groups of characteristics would the nurse expect to see in the client with schizophrenia? A. Loose association, grandiose delusions, and auditory hallucinations B. Periods of hyperactivity and irritability alternating with depression C. Delusions of jealousy and persecution, paranoia, and mistrust D. Sadness, apathy, feelings of worthlessness, anorexia, and weight loss

A. Loose association, grandiose delusions, and auditory hallucinations

The nurse is planning care for a client admitted to the psychiatric unit with a diagnosis of paranoid schizophrenia. Which nursing diagnosis should receive the highest priority? A. Risk for violence toward self or others B. Imbalanced nutrition: Less than body requirements C. Ineffective family coping D. Impaired verbal communication

A. Risk for violence toward self or others

A client is admitted to a psychiatric facility with a diagnosis of chronic schizophrenia. The history indicates that the client has been taking neuroleptic medication for many years. Assessment reveals unusual movement of the tongue, neck, and arms. Which condition should the nurse suspect? A. Tardive dyskinesia B. Dystonia C. Neuroleptic malignant syndrome D. Akathisia

A. Tardive dyskinesia

A schizophrenic client with delusions tells the nurse, "There is a man wearing a red coat who's out to get me." The client exhibits increasing anxiety when focusing on the delusions. Which of the following would be the best response? A. This subject seems to be troubling you. Let's walk to the activity room. B. There is no reason to be afraid of that man. This hospital is very secure. C. Describe the man who's out to get you. What does he look like? D. There is no need to be concerned with a man who isn't even real.

A. This subject seems to be troubling you. Let's walk to the activity room.

During the initial interview, a client with schizophrenia suddenly turns to the empty chair besides him and whispers, "Now just leave. I told you to stay home. There isn't enough work here for both of us!" What is the nurse's best initial response? A. When people are under stress, they may see things or hear things that others don't. Is that what just happened? B. I'm having a difficult time hearing you. Please look at me when you talk. C. There is no one else in the room. What are you doing? D. Who are you talking to? Are you hallucinating?

A. When people are under stress, they may see things or hear things that others don't. Is that what just happened?

The nurse must administer a medication to reverse or prevent Parkinson-type symptoms in a client receiving an antipsychotic. The medication the client will likely receive is: A. Benzotropine (Cogentin) B. diphenhydramine (Benadryl) C. propranolol (Inderal) D. haloperidol (Haldol)

A. benzotripine (Cogentin)

A man is brought to the hospital by his wife, who states for the past week her husband has refused all meals and accused her of trying to poison him. During the initial interview, the client's speech, only partly comprehensive, reveals his thoughts are controlled by delusions that he is possessed by the devil. The physician diagnoses paranoid schizophrenia. Schizophrenia is best described as a disorder characterized by: A. disturbed relationship related to inability to communicate or think clearly. B. severe mood swings and periods of low to high activity C. multiple personalities, one of which is more destructive than the others D. auditory and tactile hallucinations

A. disturbed relationship related to inability to communicate or think clearly.

The nurse knows that the physician has ordered the liquid form of the drug chlorpromazine (Thorazine) rather than the tablet form because the liquid: A. has a more predictable onset of action B. produces fewer anticholinergic effects C. produces fewer drug interactions D. has a longer duration of action

A. has a more predictable onset of action

A client with paranoid-type schizophrenia becomes angry and tells the nurse to leave him alone. The nurse should: A. tell him she'll leave for now, but will return soon B. ask him if it's okay if she sits quietly with him C. ask him why he wants to be left alone D. tell him that she won't let anything happen to him

A. tell him she'll leave for now, but will return soon

A client receiving haloperidol (Haldol) complains of a stiff jaw and difficulty swallowing. The nurse's first action is to: A. Reassure the client and administer as needed lorazepam (Ativan) IM B. Administer as needed dose of benzotropine (Cogentin) IM as needed C. Administer as needed dose of benzotropine (Cogentin) PO as ordered C. Administer as needed dose of haloperidol (Haldol) PO

B. Administer as needed dose of benzotropine (Cogentin) IM as needed

A person with antisocial personality disorder has toughness relating to others because of never having learned to: A. Count on others B. Empathize with others C. Be dependent on others D. Communicate with others socially

B. Empathize with others

The nurse formulates a nursing diagnosis of impaired social interaction related to disorganized thinking for a client with schizotypical personality disorder. Based on this nursing diagnosis, which nursing intervention takes highest priority? A. Helping the client to participate in social interactions B. Establishing a one-on-one relationship with the client C. Exploring the effects of the client's behavior on social interactions D. Developing a schedule for the clients participation in social interactions

B. Establishing a one-on-one relationship with the client

A client is admitted to the inpatient unit of the mental health center with a diagnosis of paranoid schizophrenia. He's shouting that the government of France is trying to assassinate him. Which of the following responses is most appropriate? A. I think you're wrong. France is a friendly country and an ally of the United States. Their government wouldn't try to kill you B. I find it hard to believe that a foreign government or anyone else is trying to hurt you. You must feel frightened by this. C. You're wrong. Nobody is trying to kill you. D. A foreign government is trying to kill you? Please tell me more about it.

B. I find it hard to believe that a foreign government or anyone else is trying to hurt you. You must feel frightened by this.

A client is admitted with a diagnosis of schizotypical personality disorder. Which signs would this client exhibit during social situations? A. Aggressive behaviors B. Paranoid thoughts C. Emotional affect D. Independence needs

B. Paranoid thoughts

A client has a history of chronic undifferentiated schizophrenia. Because she has a history of noncompliance with antipsychotic therapy, she'll receive fluphenazine decanoate (Prolixin Deconoate) injections every 4 weeks. Before discharge, what should the nurse include in her teaching plan? A. asking the physician for droperidol (Inapsine) to control any extrapyramidal symptoms that occur B. Sitting up for a few minutes before standing to minimize orthostatic hypotenison C. Notifying the physician if her thoughts don't normalize in a week D. Expecting symptoms of tardive dyskinesia to occur and to be transient

B. Sitting up for a few minutes before standing to minimize orthostatic hypotenison

Which of the following behaviors by a client with dependent personality disorder shows the client has made progress toward the goal of increasing problem-solving skills? A. The client is courteous B. The client asks questions C. The client stops acting out D. The client controls emotions

B. The client asks questions

Which goal is a priority for a client with a DSM-IV-TR diagnosis of delirium and the nursing diagnosis: Acute confusion related to recent surgery secondary to traumatic hip fracture? A. The client will complete ADLs B. The client will maintain safety C. The client will remain oriented D. he client will understand communication

B. The client will maintain safety

Benzotropine (Cogentin) is used to treat the extrapyramidal effects induced by antipsychotics. This drug exerts its effects by: A. decreasing the anxiety causing muscle rigidity B. blocking the cholinergic activity on the CNS C. increasing the acetylcholine in the CNS D. increasing norepinephrine in the CNS

B. blocking the cholinergic activity on the CNS

Which of the following medications would the nurse expect the physician to order to reverse a dystonic reaction? A. prochlorperazine (Compazine) B. diphenhydramine (Benadryl) C. haloperidol (Haldol) D. midazolam (Versed)

B. diphenhydramine (Benadryl)

A client with paranoid schizophrenia has been experiencing auditory hallucinations for many years. One approach that has proven effective for hallucinating patients is to: A. take an as needed dose of psychotic medication whenever they hear voices. B. practice saying "Go away" or "stop" when they hear the voices C. Sing loudly to drown out the voices and provide distractions D. go to their room until the voices go away

B. practice saying "Go away" or "stop" when they hear the voices

During the assessment stage, a client with schizophrenia leaves his arm in the air after the nurse has taken his blood pressure. His action shows evidence of: A. somatic delusions B. waxy flexibility C. neologisms D. nihilistic delusions

B. waxy flexibility

The nurse is caring for a client with schizophrenia who experiences auditory hallucinations. The client appears to be listening to someone who isn't visible. He gestures, shouts angrily, and stops shouting in mid-sentence. Which nursing intervention is the most appropriate? A. Approach the client and touch him to get his attention. B. Encourage the client to go to his room where he'll experience fewer distractions. C. Acknowledge that the client is hearing voices but make it clear that the nurse doesn't hear these voices. D. Ask the client to describe what the voices are saying.

C. Acknowledge that the client is hearing voices but make it clear that the nurse doesn't hear these voices.

A client who has been hospitalized with disorganized type schizophrenia for 8 years can't complete ADLs without staff direction or assistance. The nurse formulates a nursing diagnosis or self-care deficient: Dressing/grooming related to inability to function without assistance. What is an appropriate goal for the client? A. Client will be able to complete the ADLs independently within 1 month B. Client will be able to complete ADLs with only verbal encouragement within 1 month C. Client will be able to complete ADLs with assistance in organizing grooming items and clothing within 1 month D. Client will be able to complete ADLs with complete assistance within 1 month

C. Client will be able to complete ADLs with assistance in organizing grooming items and clothing within 1 month

Important teaching for women in their childbearing years who are receiving antipsychotic medications includes which of the following? A. Occurrence of increased libido due to medication adverse effects B. Increased incidence of dysmenorrhea while taking the drug C. Continuing previous use of contraception during periods of amenorrhea D. Instruction that amenorrhea is irreversible

C. Continuing previous use of contraception during periods of amenorrhea

Most antipsychotic medications exert which of the following effects on the CNS? A. Stimulate the CNS by blocking post synaptic dopamine, norepinephrine and serotonin receptors. B. Sedates the CNS by stimulating serotonin at the synaptic cleft. C. Depress the CNS by blocking the post synaptic transmission of dopamine, serotonin and norepinephrine D. Depress the CNS by stimulating the release of acetylcholine

C. Depress the CNS by blocking the post synaptic transmission of dopamine, serotonin and norepinephrine

A psychotic client reports to the evening nursing that the day nurse put something suspicious in his water with his medication. The nurse replies, "You're worried about your medication?" The nurses communication is: A. An example of presenting reality B. Reinforcing the client's delusions C. focusing on emotional content D. a non-therapeutic technique called mind reading

C. Focusing on emotional content

A client is receiving haloperidol (Haldol) to reduce psychotic symptoms. As he watches television with other clients, the nurse notes that he has trouble sitting still. He seems restless, constantly moving his hands and feet and changing position. When the nurse asks what is wrong, he says he feels jittery. How should the nurse manage this situation? A. Ask the client to sit still or leave the room because he is distracting other clients B. Ask the client if he is nervous or anxious about something C. Give an as needed dose of prescribed anticholinergic medication to control akathisia. D. Administer an as needed dose of haloperidol to decrease agitation.

C. Give an as needed dose of prescribed anticholinergic medication to control akathisia.

Which is the best indicator of success in the long-term management of the client? A. His symptoms are replaced by indifference to his feelings B. He participates in diversionary activities C. He learns to verbalize his feelings and concerns D. He states that his behavior is irrational

C. He learns to verbalize his feelings and concerns

A client with delusional thinking shows lack of interest in eating at meal times. Sh estates that she is unworthy of eating and that her children will die if she eats. Which nursing action would be most appropriate for this client? A. Telling the client that she may become sick and die unless she eats B. Paying special attention to the clients rituals and emotions associated with meals C. Restricting the client's access to food except at specified meal and snack times D. Encouraging the client to express her feelings at meal times

C. Restricting the client's access to food except at specific meal and snack times

A clinical instructor is correcting a nursing student's worksheet. Which instructor statement is the best example of effective feedback? A. Why did you use the client's name on your clinical worksheet? B. You were very careless to refer to your client by name on your clinical worksheet. C. Surely you didn't do it deliberately, but you breached confidentiality by using the client's name. D. It is disappointing that after being told, you're still using client names on your worksheet.

C. Surely you didn't do it deliberately, but you breached confidentiality by using the client's name.

A client has been receiving chlorpromazine (Thorazine), an antipsychotic, to treat his psychosis. Which findings should alert the nurse that the client is experiencing pseudoparkinsonism? A. Restlessness, difficulty swallowing, and pacing B. Involuntary rolling of the eyes C. Tremors, shuffling gait, and masklike face D. Extremity and neck spasms, facial grimacing, and jerky movements

C. Tremors, shuffling gait and masklike face

The definition of nihilistic delusions is: A. a false belief about what the functioning of the body B. belief that the body is deformed or defective in a specific way C. false ideas about the self, others, or the world D. the inability to carry out motor activities

C. false ideas about the self, others, or the world

The nurse is preparing for the discharge of a client who has been hospitalized for paranoid schizophrenia. The client's husband expresses concern over whether his wife will continue to take her daily prescribed medication. The nurse should inform him that: A. his concern is valid but his wife is an adult and has the right to make her own decisions B. he can easily mix the medication in his wife's food if she stops taking it C. his wife can be given a long-acting medication that is administered every 1 to 4 weeks D. his wife knows she must take her medication as prescribed to avoid further hospitalizations

C. his wife can be given a long-acting medication that is administered every 1 to 4 weeks

A client tells the nurse that the television newscaster is sending a secret message to her. The nurse suspects the client is experiencing: A. a delusion B. flight of ideas C. ideas of reference D. a hallucination

C. ideas of reference

A client with chronic schizophrenia who takes neuroleptic medication is admitted to the psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, and diaphoresis. These findings suggest which life-threatening reaction: A. tardive dyskinesia B. dystonia C. neuroleptic malignant syndrome D. akathisia

C. neuroleptic malignant syndrome

A client with schizophrenia tells the nurse, "My intestines are rotted from the worms chewing on them." This statement indicates a: A. delusion of persecution B. delusion of grandeur C. somatic delusion D. jealous delusion

C. somatic delusion

Upon evaluation of the patient's record, the nurse sees the admission was voluntary. Based on this data, the nurse expects which patient behavior? A. Fearfulness regarding treatment measures B. Anger and aggressiveness directed toward others C. An understanding of the pathology and symptoms of the diagnosis D. A willingness to participate in the planning of the care and treatment plan

D. A willingness to participate in the planning of the care and treatment plan

A dopamine receptor agonist such as bromocriptine (Parlodel) relieves muscle rigidity activity caused by antipsychotic medication by: A. Blocking dopamine receptors in the CNS B. Blocking acetylcholine in the CNS C. Activating norepinephrine in the CNS D. Activating dopamine receptors in the CNS

D. Activating dopamine receptors in the CNS

While looking out the window, a client with schizophrenia remarks, "That school across the street has creatures in it that are waiting for me." Which of the following terms best describes what the creatures represent? A. Anxiety attack B. Projection C. Hallucination D. Delusion

D. Delusion

The nurse asks a client to roll up his sleeves so she can take his blood pressure. The client replies, "If you want I can go naked for you." The most therapeutic response by the nurse is: A. You're attractive, but I'm not interested. B. You wouldn't be the first person I've seen naked. C. I will report you to the guard if you don't control yourself. D. I only need access to your arm. Putting up your sleeve is fine.

D. I only need access to your arm. Putting up your sleeve is fine.

A client who's taking antipsychotic medication develops a very high temperature, severe muscle rigidity, tachycardia, and rapid deterioration in mental status. The nurse suspects what complication of antipsychotic medication therapy? A. agranulocytosis B. Extrapyramidal effects C. Anticholinergic effects D. Neuroleptic malignant syndrome (NMS)

D. Neuroleptic malignant syndrome (NMS)

When discharging a client after treatment for a dystonic reaction, the emergency department nurse must ensure that the client understands which of the following? A. Results of treatment are rapid and dramatic but may not last B. Although uncomfortable, this reaction isn't serious C. The client shouldn't buy drugs on the street D. The client must take benztropin (Cogentin) as prescribed to prevent a return of symptoms

D. The client must take benztropin (Cogentin) as prescribed to prevent a return of symptoms

Which nursing statement is a good example of the therapeutic communication technique of focusing? A. Describe one of the best things that happened to you this week. B. I'm having a difficult time understanding what you mean. C. Your counseling session is in 30 minutes. I'll stay with you until then. D. You mentioned your relationship with your father. Let's discuss that further.

D. You mentioned your relationship with your father. Let's discuss that further.

A client with schizophrenia hears a voice telling him he is evil and must die. The nurse understands that the client is experiencing: A. a delusion B. flight of ideas C. ideas of reference D. a hallucination

D. a hallucination

Nursing care for a client with schizophrenia must be based on valid psychiatric and nursing theories. The nurse's interpersonal communication with the client and specific nursing interventions must be: A. clearly identified with boundaries and specifically defined roles B. warm and non-threatening C. centered on clearly defined limits and expression of empathy D. flexible enough for the nurse to adjust the plan of care as the situation warrants

D. flexible enough for the nurse to adjust the plan of care as the situation warrants

A client is admitted to the psychiatric unit of a local hospital with chronic undifferentiated schizophrenia. During the next several days, the client is seen laughing, yelling, and talking to herself. This behavior is characteristic of: A. delusion B. looseness of association C. illusion D. hallucinations

D. hallucinations

What medication would probably be ordered for the acutely aggressive schizophrenic client? A. chlorpromazine (Thorazine) B. haloperidol (Haldol) C. lithium carbonate (Lithonate) D. amitriptyline (Elavil)

haloperidol (Haldol)