Psychotic Disorder

A client received haloperidol 12 hours previously. The client develops an oculogyric crisis and tongue protrusion. Which of the following is a nursing priority intervention a) Administering diazepam as ordered b) Administering chlorpromazine as ordered c) Administering midazolam as ordered d) Administering diphenhydramine as ordered

- Administering diphenhydramine as ordered Explanation: - The client is experiencing a dystonic reaction to the administration of haloperidol that needs to be reversed by diphenhydramine. - Chlorpromazine also causes this type of reaction and would not be indicated for use in this client. - Midazolam and diazepam would cause drowsiness but do not have the properties to reverse the dystonic state.

The client thinks he is being followed by foreign agents who are after secret papers in his briefcase. What thought process does this indicate? a) Idea of influence. b) Idea of reference. c) Delusion of persecution. d) Delusion of grandeur.

Delusion of persecution. Explanation: - The client's thought process is best defined as a delusion of persecution. - An idea of reference assumes that the remarks and behavior of others apply to oneself. - An idea of influence refers to the belief that people or objects have control over one's behavior. - A delusion of grandeur involves an exaggerated idea of one's importance or identity

The nurse is admitting a client to the psychiatric unit. Suddenly, the client states, "They're all plotting to destroy me. Isn't that true?" Which would be the most appropriate response? a) "That doesn't make any sense; nurses are helpers, not murderers." b) "Please explain that to me." c) "What reason would people have to want to destroy you?" d) "People here are trying to help you if you will let them."

Please explain that to me." Explanation: Clients with fixed false beliefs truly believe the content of the delusion. Arguing or explaining will not help as in the other options. Initially the nurse needs to know the content and depth of the delusion while the client is being admitted. Then the nurse needs to focus on how the client feels about the delusion or distract the client from the delusion during the conversation.

A nurse is caring for a client who experiences false sensory perceptions that have no basis in reality. These perceptions are known as: a) neologisms. b) delusions. c) loose associations. d) hallucinations.

hallucinations. Correct Explanation: Hallucinations are visual, auditory, gustatory, tactile, or olfactory perceptions that have no basis in reality. Delusions are false beliefs, rather than perceptions, that the client accepts as real. Loose associations are rapid shifts among unrelated ideas. Neologisms are bizarre words that have meaning only to the client.

Important teaching for a client receiving risperidone should include advising the client to: a) notify the physician if he notices an increase in bruising. b) be sure to take the drug with a meal because it can severely irritate the stomach. c) discontinue the drug if he gains weight. d) maintain a therapeutic level by doubling a dose if he misses a dose.

notify the physician if he notices an increase in bruising. Correct Explanation: Bruising may indicate blood dyscrasias, so notifying the physician about increased bruising is very important. The client shouldn't double the drug dose. This drug doesn't irritate the stomach, and weight gain isn't an adverse effect of risperidone therapy. (less)