Mental Health Nursing Test 5- Ch 17
A client diagnosed with paranoid schizophrenia is still withdrawn, unkempt, and unmotivated to get out of bed. A mental health aide asked the nurse why he is this way after being on haldol 10 mg for seven days. The nurse should tell the health aide a. Haldol is most effective with a positive symptoms of schizophrenia b. He'll be less withdrawn and unmotivated when the haldol takes effect c. His haldol dose probably needs to be increased again d. His lack of motivation is a common side effect of the haldol
a
A client diagnosed with schizophrenia is brought to the hospital from a group home where he became agitated, threw a chair at another client, and has been refusing medication for 8 weeks. the client exhibits a flat affect, is not caring for his hygiene, and has become increasingly withdrawn and asocial. The physician orders treatment with Risperdal to improve the client's negative and positive symptoms of schizophrenia. when evaluating the drug's effectiveness on the client's negative symptoms, the nurse should expect improvement in which of the following? a. Apathy, affect, social isolation b. agitation, delusions, hallucinations c. hostility, ideas of reference, tangential speech d. aggression, bizarre behavior, illusions
a
The nurse is assessing a client who is taking an antipsychotic medication. Which of the following symptoms is uniquely indicative of neuroleptic malignant syndrome and requires immediate attention? a. Very high temperature b. Muscle rigidity c. Tremors d. Altered consciousness
a
What assessment findings mark the prodromal stage of schizophrenia? a. withdrawal, misinterpreting, poor concentration, and preoccupation with religion b. auditory hallucinations, ideas of reference, thought insertion, and broadcasting c. stereotyped behavior, echopraxia, echolalia, and waxy flexibility d. loose associations, concrete thinking, and echolalia neologisms
a
A patient's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating? a. Aloofness, haughtiness, suspicion b. darting eyes, tilted head, mumbling to self c. elevated mood, hyperactivity, distractibility d. performing rituals, avoiding open places
b
When administering antipsychotics to a client with paranoid schizophrenia, the nurse understands that the newer atypical antipsychotics such as Zyprexa and Risperdal are more effective than the older medications and treating the negative symptoms of schizophrenia because of which of the following? a. Serotonin and gamma-aminobutyric acid (GABA) levels are not affected b. Dopamine and serotonin receptors are blocked c. GABA and norepinephrine levels are increased d. Norepinephrine and dopamine receptors are blocked
b
A newly admitted client describes her mission in life as one of saving her son by eliminating the provocative sluts of the world. There are several attractive young women on the unit. What should the nurse do first? a. Ask the client for her definition of provocative sluts b. Ask the young female clients on the unit to dress less provocatively c. Ask the client to discuss her concerns in the next group session d. Ask the client to inform the staff if she has negative thoughts about other clients
d
A patient 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? a. poverty of content b. concrete thinking c. neologisms d. paranoia
d
Which patient with schizophrenia would be able to have the lowest score in global assessment of functioning? a. 39 years old; paranoid ideation since age 35 b. 32 years old; diagnosed as catatonic at age 24 years; stable for three years c. 19 years old; diagnosed with undifferentiated schizophrenia at age 17 d. 40 years old; disorganized schizophrenia since age 18; frequent relapses
d
Withdrawn patients with schizophrenia: a. Universally fear sexual involvement with therapists b. Are socially disabled by the positive symptoms of schizophrenia c. Exhibit a high degree of hostility as evidenced by rejecting behavior d. Avoid relationships because they become anxious with emotional closeness
d
A client diagnosed with undifferentiated schizophrenia gained 50 pounds in six months while taking zyprexa. After seeing her psychiatrist to change the medication to GeoDon, the client tells the nurse, "I don't want to take this GeoDon either. I can't gain anymore weight." Which response by the nurse is most appropriate for this client? a. Geodon causes less weight gain than the other atypical antipsychotics b. We can give it to you as an injection rather than in capsule form c. Abnormal movements are not as common with GeoDon d. You can take it just before bedtime, so you won't need a snack
a
A patient with schizophrenia begins to talk about "volumes" hiding in the warehouse at work. The term "volumes" should be documented as: a. neologism b. concrete thinking c. thought insertion d. idea of reference
a
An outpatient client who has been receiving Haldol for 2 days develops muscular rigidity, altered consciousness, a temperature of 103 and trouble breathing on day 3. The nurse interprets these findings as indicating which of the following? a. neuroleptic malignant syndrome b. tardive dyskinesia c. extrapyramidal adverse effects d. drug-induced Parkinsonism
a
Client reports that men in blue clothes keep looking in her window and talking about her. Which of the following responses by the nurse is most appropriate? a. Those men are grounds keepers. They're talking about their work, not you b. Don't take things so personally. Not everyone who is talking is talking about you c. Let's not pay attention to the man. Let's play cards instead d. I'll close the drapes so you can't see them in
a
A patient with paranoid schizophrenia is hospitalized after arguing with co-workers and threatening to harm them. The patient is aloof and suspicious and says, "Two staff members I saw talking were plotting to kill me." Based on the gathered data at this point, which nursing diagnoses relate? Select all that apply a. risk for directed violence b. disturbed thought processes c. risk for loneliness d. spiritual distress e. social isolation
a,b
A client diagnosed with undifferentiated schizophrenia is being discharged on Abilify 5 mg every night. When developing the teaching plan about the most common adverse effects, which of the following should the nurse include? Select all that apply a. headaches that will subside in a few weeks b. transient mild anxiety c. insomnia d. torticollis e. pill rolling movements
a,b,c
A client who has been stabilized on medications for several months is at the clinic for a medicine check. During the conversation with the nurse, the client suddenly jumps up, begins pacing and wrings her hands. In what order should the nurse do the following interventions from first to last? a. Walk with the client to help decrease her anxiety b. Discuss productive ways to solve her problems causing anxiety c. Share observations about her anxiety related behaviors d. Ask the client about the sources of her anxiety
a,c,d,b
What is the most appropriate long term goal for an outpatient client with chronic undifferentiated schizophrenia who has been withdrawn from friends and family for 3 weeks a. calling his mother once a day b. attending day therapy three times a week c. allowing two friends to visit every day d. remaining out of bed for 10 hours a day
b
A nurse at the mental health clinic plans a series of psychoeducational groups for persons with schizophrenia. Which two topics would take priority a. how to complete an application for employment b. the importance of correctly taking your medication c. how to dress when attending community events d. how to give and receive compliments e. ways to quit smoking
b,e
A 79-year-old woman is brought to the outpatient clinic by her daughter for a routine medication evaluation. The daughter reports that her mother is quite stable and has no adverse effects from the Risperdal she is taking. Then the daughter says, "I just think my mother could be even better if she was on a larger dosage. My son takes 1 mg of Risperdal every day and my mother is only on .5 mg." What is the most helpful response by the nurse? a. Maybe your son is sicker than your mother is b. We could increase your mothers dosage if you want c. Older clients generally need only 1/3 to 1/2 the dose of younger people d. I'm not seeing the symptoms of illness in your mother. Let's wait until the next visit
c
A client is aware that he is experiencing auditory hallucinations as a result of his paranoid schizophrenia. At this point, which of the following is the most appropriate response for the nurse to make? a. I know you hear voices, but I don't hear them b. Time in medicines will make the voices go away c. What seems to help make the voices less bothersome d. The only voices I hear right now are yours and mine
c
An outpatient client who has a history of paranoid schizophrenia and chronic alcohol dependency has been taking Risperdal for several months. She reports that she stopped drinking for days ago. The client is very frightened by the tactile hallucinations of bugs crawling under her skin. Which of the following factors should the nurse incorporate into the plan of care when explaining the tactile hallucinations? a. Alcohol intoxication b. Ineffectiveness of risperdal c. Alcohol withdrawal d. Interaction of alcohol in resperdal
c
When asked about her stresses before admission, an anxious client stares blankly at the nurse and mutters unintelligibly. Which of the following descriptions of the client's behavior should the nurse document in the client's chart? a. client cannot answer any questions asked at this time b. client is incorporative during admission procedure, refusing to answer any questions c. client responded to questions with a blank look and incomprehensible mumble d. client stared at wall when asked questions and was disoriented and incoherent
c
A client diagnosed with schizophrenia is being switched to Long acting injection Risperdal Consta. He is told that he will remain on his oral dose of Risperdal daily for approximately one month. The client says, "I didn't have to take pills when I was on Prolixin decanoate shots in the past." The nurse should tell the client: a. Taking Prolixin decanoate orally and by injection would not be as effective as the injection alone b. Risperdal Consta is less potent than Prolixin decanoate c. The doctor didn't believe you would take both the pills and the Prolixin decanoate d. Risperdal Consta initially takes a little longer to reach the ideal blood level
d
A client is complaining about blurred vision for days after taking Haldol, Cogentin, Seroquel, and BuSpar. Which of the following medications should the nurse expect as the most likely cause of this adversity effect? a. BuSpar b. Saroquel c. Haldol d. Cogentin
d
A client with undifferentiated schizophrenia tells the nurse that he doesn't go out much because he doesn't have anywhere to go and he doesn't know anyone in the apartment where he's staying. Which of the following actions is most beneficial for the client at this time? a. Encouraging him to call his family to visit more often b. making an appointment for the client to see the nurse daily for 2 weeks c. thinking about the need for rehospitalization for the client d. arranging for the client to attend day treatment at the clinic
d
A health care provider considers which antipsychotic medication to prescribe for a patient with schizophrenia who has auditory hallucinations. Which drug should the nurse advocate? a. clozaril b. geodon c. zyprexa d. abilify
d
A community mental health nurse wants to establish a relationship with a very withdrawn patient diagnosed with schizophrenia. The patient lives at home with a supportive family. Select the nurses best plan. a. Visit daily for four days, then visit every other day for one week; stay with the patient for 20 minutes; except silence; state when the nurse will return b. Arrange to spend one hour each day with the patient; focus on asking questions about what the patient is thinking or experiencing; avoid silences c. Visit twice daily; sit beside the patient with a hand on the patient's arm; leave if the patient does not respond within 10 minutes d. Visit every other day; remind the patient of the nurses identity; encourage the patient to talk while the nurse works on reports
a
A newly admitted client diagnosed with paranoid schizophrenia is pacing rapidly and ringing his hands. He states that another client is out to get him. Then he states, "protect me, select me, reject me." The nurse should next: a. Administer his oral PRN Ativan and Haldol b. Placed a client in temporary seclusion before he has a chance to hurt others c. Call the physician for an order for restraints d. Ask the other clients to leave the immediate area
a
When a client who exhibits feelings of inferiority is asked to attend group activities, she gets more anxious. Within 10 minutes, she begins ridiculing others in the group and receives negative attention. Which of the following statements best reflects the nurses interpretation of the clients behavior? Select all that apply a. Increased anxiety levels can cause defensive coping b. Negative attention reinforces acting out behaviors c. Negative attention is better than no attention at all d. Increased anxiety as a reason to exclude the client from groups e. The client needs medication to control her anxiety
a,b,c
The family members of a patient newly diagnosed with paranoid schizophrenia state that they do not understand what has caused the illness. The nurse's response should be based on which models? Select all that apply a. neurobiological b. developmental c. family theory d. genetic f. stress
a,d
A patient diagnosed with paranoid schizophrenia says, "My coworkers are out to get me. I also saw two doctors plotting to kill me. How does this patient perceive the environment? a. Disorganized b. Dangerous c. Supportive d. Bizarre
b
A patient with schizophrenia begins a new prescription for lurasidone HCI (Latuda). The patient is 5'6" tall and currently weighs 204 pounds. Which topic is most important for the nurse to include in the teaching plan related to this medication a. how to recognize tardive dyskinesia b. weight management strategies c. ways to mange constipation d. sleep hygiene measures
b
A patient with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive, but the patient continues to have apathy, poverty of thought, and social isolation. the nurse expects a change to which medication? a. haldol b. zyprexa c. thorazine d. benadryl
b
A 77-year old client is brought to the emergency department by her son. The client is complaining of a severe headache and lack of sleep because, "I'm so worried about everything." her son says that she has heart failure and chronic schizophrenia. "In addition to all of her heart medicines, she is on Abilify, which was increased to 30 mg by her family doctor 3 days ago." In addition to documenting all of the client's medications and exact dosages, the nurse should particularly investigate which of the following? Select all that apply a. the qualifications of the client's family doctor b. the client's symptoms of schizophrenia c. the dose of aripiprazole d. the client's symptoms of heart failure e. the client's relationship with her son
b,c,d
A patient with schizophrenia has taken prolactin 5 mg orally twice daily for three weeks. The nurse no assess is a shuffling propulsive gait, a mask like face, and drooling. Which term applies to these symptoms? a. Neuroleptic malignant syndrome b. Hepatocellular effects c. Pseudoparkinsonism d. Akathisia
c
A client is admitted to the unit with a diagnosis of Axis I delusional disorder, percursetory type. The nurse includes the nursing diagnosis defensive coping secondary to suspiciousness as evidenced by the statement, "My wife and coworker are conspiring against me," in the client's plan of care. Which statement about the client is an expected outcome for this nursing diagnosis? a. demonstration an absence of hostile behavior b. express own needs using assertive communication c. use adaptive coping strategies appropriately d. accurately interpret the behaviors of his wife and coworker
d
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 nurse's best response. a. "Why are you laughing?" b. "Please share the joke with me." c. "I don't think I said anything funny." d. "You're laughing. Tell me what's happening."
d
A patient diagnosed with disorganized schizophrenia says, "It's beat. Time to eat. No room for the cat." What type of verbalization is evident? a. neologism b. idea of reference c. thought broadcasting d. associative looseness
d
A patient diagnosed with paranoid schizophrenia angrily tells a nurse, "You act like a homosexual! No one trusts you or wants to be around you." Select the most likely analysis. The patient: a. is showing reaction formation in response to feelings of abandonment b. is unleashing unconscious, hostile feelings toward the nurse c. is dwelling on others' shortcomings, thus placing them on the defensive d. may be projecting homosexual urges
d
A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 10:30 am. By noon, the patient has difficulty swallowing and is drooling. By 4:00 pm, vital signs are body temperature, 102.8; pulse, 110 beats per minute; respirations, 26 breaths per minute; and bp, 150/90. The patient is diaphoretic. Select the nurse's best analysis and action a. agranulocytosis. Institue reverse isolation b. tardive dyskinesia. Withhold the next dose of medication c. cholestatic jaundice. Begin a high protein, high cholesterol diet d. neuroleptic malignant syndrome. Immediately notify the healthcare provider
d
A patient with schizophrenia anxiously says, "I can see the left side of my body merging with the wall, they my face appears and disappears in the mirror". While listening, the nurse should: a. sit close to the patient b. place an arm protectively around the patient's shoulders c. place a hand on the patient's arm and exert light pressure d. maintain a normal social interaction distance from the patient
d
When preparing the teaching plan for a client who has to start Clozaril which of the following is crucial to include? a. Description of akathisia and drug-induced parkinsonism b. Measures to relieve episodes of diarrhea c. The importance of reporting insomnia d. And emphasis on the need for weekly blood tests
d
a patient with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It blows away. Get it?" Select the nurse's best response a. nothing you are saying is clear b. your thoughts are very disconnected c. try to organize your thoughts, m and then tell me again d. I am having difficulty understanding what you are saying
d
A client is being successfully treated with closet rail. Which of the following statements by the client reflects a need for further teaching about managing the drugs adverse effects? a. If I eat too many fruits, I'll get constipated b. I need to take the medications with food to avoid nausea c. I have to get up slowly so I don't get dizzy d. Sometimes I have to push myself because I'm sleepy
a
A patient with schizophrenia is acutely disturbed and violent. After several doses of Haldol the patient is calm. Two hours later the nurse sees the patient's head rotating to one side in his deposition; the lower jaw is thrust forward, and the patient is drooling. Which problem is most likely? a. Acute dystonic reaction b. Tardive dyskinesia c. Waxy flexibility d. Akathisia
a
The nurse hands the medication cup to a client sho is psychotic and exhibiting concrete thinking, and tells the client to take his medicine. The client takes the cup, holds it in his hand, and stares at it. Which of the following should the nurse do next? a. tell the client to put the medicine in his mouth and swallow with some water b. instruct the client to sit in the dayroom and wait for the nurse to assist him c. ask another staff member to stay with the client until he takes the medication say nothing and wait for the client to put the medication in his mouth and swallow it
a
A newly admitted patient with schizophrenia says, "the voices are bothering me. They yell and tell me I'm bad. I have got to get away from them." Select the nurse is most helpful reply a. Do you hear the voices often b. Do you have a plan for getting away from the voices c. I'll stay with you. Focus on what we are talking about, not the voices d. Forget the voices, and ask some other patients to play cards with you
c
a patient with schizophrenia has auditory hallucinations, delusions of grandeur, poor personal hygiene and motor agitation. Which assessment finding would the nurse regard as a negative symptom of schizophrenia a. auditory hallucinations b. delusions of grandeur c. poor personal hygeine d. motor agitation
c
During a home visit, the nurse discovers that a client is less verbal, less active, less responsive to directions, severely anxious, and more stuporous. The nurse interprets these findings to indicate that the client needs: a. a sleep aid b. a clinic appointment c. an increase in medication d. hospitalization
d
The family of a patient with undifferentiated schizophrenia is unfamiliar with the illness and the family's role in recovery. Which type of therapy should the nurse recommend? a. psychoeducational b. psychoanalytic c. transactional d. family
a
A client with a long history of paranoid schizophrenia is readmitted voluntarily after missing his last two injections of Haldol decanoate. He reports, "I'm not sleeping much and my friend says I smell from not showering. God is telling me to protect myself from others. My parents are sick and tired of me and my illness. They wish I were dead." Which of the following admission notes by the nurse contains assumptions and potentially false accusations? Select all that apply a. Client has been non-compliant with his medications, causing decreased sleep and activities of daily living, increased auditory hallucinations, and paranoid delusions about his parents harming him b. Client has missed two injections of Haldol decanoate and was admitted voluntarily. He reports he has decreased sleep and showering and that he hears gods voice telling him to protect himself from others. He stated, "my parents are sick and tired of me and my illness. They wish I were dead." c. Client has missed two doses of Haldol decanoate. He's not sleeping and showering. He has a strained relationship with his parents and delusions that they want him dead. Voluntary admission to restart Haldol decanoate. d. Client admitted for noncompliance with Haldol decanoate injections, sleep disturbance, poor hygiene, auditory hallucinations, and suspiciousness of his parents. Needs to be monitored for suicidal and homicidal ideation. e. Client admitted because of hallucinations and delusions. His parents may be abusing him. He states he has not taken his medications for two days.
a,c,d,e
A client states that she hears gods voice telling her that she has stand and needs to punish herself. Which response by the nurse is most important? a. How do you think you will be punished? b. Please tell staff when you think you need to punish yourself c. What exactly do you think you have done to be punished d. Let's talk about your strengths
b
A client who is diagnosed with undifferentiated schizophrenia eight years ago is admitted to a unit because of increasingly severe mood swings. His diagnosis is changed to schizoaffective disorder. He asked the nurse, "so what now? My risperidone (Risperdal) is just not doing the job." How should the nurse respond? a. The doctor will probably increase the dosage of your Risperdal b. With your mood swings, we may need to take a mood stabilizer along with your Risperdal c. The doctor will have to see how severe your mood swings are before he decides what to do d. If you are not suicidal, no change will be made in your medications
b
A patient has taken Stelazine 30 mg a day or Aleve for three years. The clinic nurse Notes that the patient grimaces and constantly smacks both lips. The patient's neck and shoulders twist and a slow, snake light motion. Which problem with the nurse suspect? a. Agranulocytosis b. Tardive dyskinesia c. Tourette syndrome d. Anticholinergic effects
b
A patient with catatonic schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which patient needs are of priority importance? a. Psycho social b. Physiologic c. Self actualization d. Safety and security
b
A patient with catatonic schizophrenia is semi step breast, demonstrates little spontaneous movement, and has waxy flexibility. The patient's activities of daily living are severely compromised. Inappropriate outcome is that the patient will: a. Demonstrate increased interest in the environment by the end of week one b. Perform self-care activities with coaching by the end of day three c. Gradually take the initiative for self-care by the end of week two d. Except tube feeding without objection by day two
b
A person has had difficulty keeping a job because of arguing with coworkers and accusing them of conspiracy. Today the person shouts, "They're all plotting to destroy me. Isn't that true?" Select the nurse's 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. No, 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
b
The parents of a 20 year old female client diagnosed with paranoid schizophrenia admitted 4 days ago are attending a family psychoeducation group in the hospital. Which of the following statements by the mother indicates that she understands her daughter's illness and management? a. I know that I'll have to do everything for my daughter when she comes home b. Tasks as simple as getting out of bed and showering in the morning may be difficult for her c. I know that visits from her friends at home should be discouraged for awhile d. she won't experience a relapse as long as she takes her prescribed medication
b
The plan of care for an outpatient client with chronic undifferentiated schizophrenia includes Risperdal therapy. the nurse prepares to administer this drug based on the understanding of which of the following? a. the positive symptoms of CUS are usually more prominent than the negative symptoms b. agranulocytosis is less of a risk with Risperdal therapy c. traditional antipsychotics help with negative symptoms, but not as well as Risperdal does d. Risperdal is less expensive than traditional antipsychotics
b
A client with schizophrenia comes to the outpatient mental health clinic 5 days after being discharged from the hospital. The client was given a 1 week supply of clozaril. The client tells the nurse that she has too much saliva and frequently needs to spit. The nurse interprets the client's statement as indicating which of the following? a. Delusion, requiring further assessment b. Unusual reaction to clozaril c. Expected adverse effect of clozaril d. unresolved symptom of schizophrenia
c
the client with an Axis I diagnosis of schizophrenia, undifferentiated type, is acutely psychotic and exhibits religious delusions and hallucinations, loose associations, and concrete thinking. When the nurse offers the client her medication, the client states, "I don't need that. God will heal me." the nurse should respond to the client by saying: a. god helps those who help themselves b. god wants you to take your medicine c. god is important in your life, but the medicine will help you too d. this medicne will help clear your thoughts and decrease anxiety
c
A patient with schizophrenia and auditory hallucinations anxiously tells the nurse, "the voice is telling me to do things." Select the nurse's priority assessment question a. how long has the voice been directing your behavior? b. does what the voice tells you to do frighten you? c. do you recognize the voice speaking to you? d. what is the voice telling you to do?
d
A patient 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, "Volmers are hiding in the house." the nurse can correctly assess the information as an indication of: a. need for psychoeducation b. medication noncompliance c. chronic deterioration d. relapse
d
For the client with catatonic behaviors, which of the following should the nurse use to determine that the medication administered as needed has been most effective in the long term? a. the client can move all extremities occasionally b. the client walks with the nurse to her room c. the client responds to verbal directions to eat d. the client initiates simple activities without directions
d
The nurse identifies a nursing diagnosis of dressing or grooming self-care deficit related to apathy, as evidenced by an inability to shower and dress herself for a female client diagnosed with schizophrenia. When planning care for this client, which of the following outcomes should the nurse expect the client to achieve by the end of four days? a. Verbalize the need to shower and dress herself b. recognize the need to shower and dress herself c. explain reasons for showering and dressing herself d. perform showering and dressing herself
d
Which of the following statements indicates increased insight by the client about her newly diagnosed paranoid schizophrenia being stabilized on medications? a. Now that the voices are gone, I can decrease my medications b. I would feel better if I knew there wasn't poison in my food c. Since I feel better, I know I can restart school next week d. The voices go away when I tell them to, except if I'm really nervous
d
A client has been perceiving her roommate stuffed animal as her own dog at home. The nurse determines that this miss perception of reality (illusion) is improving when the client makes which of the following statements? a. Jan's stuffed dog looks somewhat like my dog, Trixie b. Jan's dog and my dog could be twins c. I wish Jan hadn't had my dog stuffed d. I guess Jan needs a dog as much as I do
a
A client is becoming agitated during a discussion group. She states, "I know that all of you hate me". She leaves the group and goes to her room. Which action by the nurse is most therapeutic for the client? a. After group, ask the client to talk to the nurse about her concerns b. Ask the client to return to group and share her feelings c. Explain to group members about the clients problems d. Ask the group members to apologize to the client individually
a
A client who is suspicious of others including staff is brought to the hospital wearing a wrinkled dress with stains on the front. Assessment also reveals a flat affect, confusion and slow movements. What goal should the nurse identify as the initial priority when planning this clients care? a. Helping the client feel safe and accepted b. Introducing the client to other clients c. Giving the client information about the program d. Providing the client with clean comfortable clothes
a
A client with chronic undifferentiated schizophrenia has positive and negative symptoms of schizophrenia but does not meet the criteria for paranoid, disorganized, or catatonic schizophrenia. Based on the interpretation of this information, the nurse should expect the client to exhibit which of the following as the most likely symptoms? a. auditory hallucinations and asocial behaviors b. preoccupation with persecutory delusions and hallucinations c. grossly disorganized behaviors and speech d. immobility and waxy flexibility
a
A nurse works with a patient with paranoid schizophrenia regarding the importance of medication management. the patient repeatedly says, "I don't like taking pills." Family members say they feel helpless to foster compliance. Which treatment strategy should the nurse discuss with the health care provider? a. use of a long-acting antipsychotic preparation b. addition of a benzodiazepine such as lorazepam (Ativan) c. Adjunctive use of an antidepressant such as elavil d. prolonged hospitalization; this patient is not ready for discharge
a
A patient with delusions of persecution about being poisoned has refused all hospital meals for three days. Which intervention is most likely to be acceptable to the patient? a. Allowing the patient to have supervised access to food vending machines b. Allowing the patient to telephone a local restaurant to deliver meals c. Offering to taste each portion on the tray for the patient d. Providing tube feedings or total parenteral nutrition
a
A patient with schizophrenia is acutely disturbed and violent. After several doses of Haldol the patient is calm. Two hours later the nurse sees the patient's head rotating to one side in his deposition; the lower jaw is thrust forward, and the patient is drooling. Which intervention by the nurse is indicated? a. Administer Benadryl 50 mg IM from the PRN medication administration record b. Reassure the patient that the symptoms will subside. Practice relaxation exercises with the patient c. Give Artane 5 mg orally at the next regularly scheduled medication administration time d. Administer atropine sulfate to milligrams subcut from the PRN medication administration record
a
When a patient with paranoid 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 common side effects should the nurse validate with the patient? a. sedation and muscle stiffness b. sweating, nausea, and diarrhea c. mild fever, sore throat, and skin rash d. headache, watery eyes, and runny nose
a
When conducting a mental status examination with a newly admitted client who has an excess one diagnosis of paranoid schizophrenia, the client states, "I'm being followed; it's not safe. They're monitoring my every move." In which of the following areas of the mental status examination should the nurse document this information? a. Thought content b. Quality of speech c. Insight d. Judgment
a
While conducting a home visit for a client diagnosed with paranoid schizophrenia discharged 1 week ago, the client's mother tearfully states, "I can hardly sleep because I'm so worried about my daughter. I'm afraid to leave her alone in the house. What if something should happen while I'm gone?" Which of the following problems related to the caregiver would be the most inclusive one for the nurse to incorporate into the client's plan of care? a. caregiver role strain b. anxiety c. fear d. disturbed sleep pattern
a
A client is receiving Haldol decanoate. He begins to complain of stiff muscles, restlessness, and internal jumpiness. The client has all of the following medications ordered as needed. Which one is the most appropriate for the nurse to administer to decrease the clients symptoms? a. Lorazapam (Ativan) b. Benztropine mesylate (Cogentin) c. Trazodone (Desyrel) d. Olanzipine (Zyprexa)
b
A client is sitting in the corner of the day room cocking his head to one side as if you hear something, but no one is nearby. The nurse suspect he is having auditory hallucinations. Which of the following question should the nurse ask first? a. Are you seeing someone other than me b. What are you hearing right now c. What is going on with you right now d. Do you want to go to the recreation room
b
A client reports having thoughts of being followed by foreign agents who are after his secret papers. Which response by the nurse is most appropriate when responding to the clients disturbed thought process? a. I don't see any foreign agents b. I think these thoughts are frightening to you c. I don't know what you mean d. I'd like you to come to group with me right now
b
A client who is neatly dressed and clutching a leather briefcase tightly in his arms scans the adult inpatient unit on his arrival at the hospital and backs away from the window. The client requests that the nurse move away from the window. The nurse recognizes that doing as the client requested is contraindicated for which of the following reasons? a. The action will make the client feel that the nurse is humoring him b. The action indicates non-verbal agreement with the client false ideas c. The client will then think that he will have his way when he wishes d. The nurse will be demonstrating a lack of composure over the situation
b
A newly admitted client with an acute exacerbation of psychotic symptoms of chronic undifferentiated schizophrenia is having trouble deciding whether to live in a group home or a supervised apartment. When caring for this client, which of the following activities is most appropriate for the nurse to ask the client to do initially? a. list the pros and cons of each housing option b. choose between apple and orange juice for breakfast c. identify why the client cannot live in an unsupervised apartment d. decide which staff member the client would like to have today
b
A newly admitted patient diagnosed with paranoid schizophrenia is hyper vigilant 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 a. echolalia b. idea of reference c. delusion of infidelity d. auditory hallucinations
b
A nurse observes a patient who is in a catatonic state and standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile with this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon? a. Echolalia b. Waxy flexibility c. Depersonalization d. Thought withdrawal
b
A pregnant client in her third trimester is started on Thorazine 25 mg four times daily. Which of the following instructions is most important for the nurse to include in the clients teaching plan? a. Don't drive because there's a possibility of seizures occurring b. Avoid going out in the sun without sunscreen with a sun protection factor of 25 c. Stop the medication immediately if constipation occurs d. Tell your doctor if you experience an increase in blood pressure
b
A young client diagnosed with paranoid schizophrenia is talking with the nurse. "You know, when I thought everyone was out to get me, I was staying in my apartment all the time. Now, I'd like to get out and do things again." What is the best initial response by the nurse? a. With whom do you want to do things b. What activities did you enjoy in the past c. What kind of transportation do you use d. How much money can you spend
b
At an outpatient visit 3 months after discharge from the hospital, a client says he has stopped taking his Zyprexa even though he controls his symptoms of schizophrenia better than other medications. "I have gained 20 pounds already. I can't stand any more." Which response by the nurse is most appropriate? a. I don't think you look fat, why do you think so? b. I can help you with a diet and exercise plan to keep your weight down c. You can be switched to another medicine d. Your weight gain will level off if you stay on your medication three more months
b
FaceTime FaceTime the parent of a young adult client diagnosed with paranoid schizophrenia is asking questions about his sons antipsychotic medication Geodon. Which of the following statements by the father reflects a need for further teaching? a. If he experiences restlessness or muscle stiffness, he should tell the doctor b. I should give him Bensztropine (Cogentin) to help prevent constipation from the GeoDon c. If he becomes dizzy, I'll make sure he doesn't drive d. The GeoDon should help him be more motivated and less withdrawn
b
In a family education group for those who have relatives with paranoid schizophrenia, which of the following comments indicates the need for further teaching about symptom management? a. When the clients get overwhelmed, it's best if they spend some time in their room b. The more we push the clients to spend time with friends, the more their voices decrease c. Until we get the clients up and going, they seem to have no motivation to do anything d. We still have to remind the clients that we don't hear the voices they do
b
The mother of a client with chronic undifferentiated schizophrenia calls the visiting nurse in the outpatient clinic to report that her daughter has not answered the phone in 10 days. "She was doing so well for months. I don't know what's wrong. I'm worried." Which of the following responses by the nurse is most appropriate? a) "Maybe she's just mad at you. Did you have an argument?" b) "She may have stopped taking her medications. I'll check on her." c) "Don't worry about this. It happens sometimes." d) "Go over to her apartment and see what's going on."
b
The nurse notes that a client sitting in a chair has not gotten up in 1 hour. The client does not respond to verbal direction, and her arm has been extended over the armrest for 30 minutes. which of the following should the nurse do next? a. Assist the client out of the chair to lead her back to bed b. give prn-ordered doses of Haldol and Ativan c. Ask the client to describe what is being experienced right now d. sit quietly with the client until she begins to respond
b
The wife of a client diagnosed with paranoid schizophrenia visits two days after her husband's admission and states to the nurse, "why isn't he eating? He still talking about his food being poisoned." Which of the following appraisals by the nurse is most accurate? a. The wife's inquiry is reasonable b. Education about her husband's medications is needed c. Her expectations of her husband are realistic d. An increase in the clients medication is indicated
b
Which action by the nurse is likely to increase the anxiety and suspiciousness of a client who is delusional? a. informing the client of schedule changes b. whispering with others where the client can observe c. telling the client gently that the nurse does not share the client's view d. inviting the client to join in leisure activities
b
Which symptoms are expected for a patient with disorganized schizophrenia? a. Extremes of motor activity, from excitement to stupor b. social withdrawal and ineffective communication c. severe anxiety with ritualistic behavior d. highly suspicious, delusional behavior
b
Hospital-based care has become more oriented to crisis intervention, criteria for admission to the hospital have also changed. Which clients have the priority for admission to an acute care facility? Select all that apply a. Clients who live alone b. Clients who are acutely psychotic c. Clients who are acutely depressed d. Clients who are dangerous to self or others e. Clients who are not complying with medication regimens
b,d
Police bring a client to the emergency department after she threatens to kill her ex-husband. She states emphatically, "the police should bring him in, not me. He's paranoid about my dating and has been stocking me for weeks. He's probably off his medicines. His case manager and the police won't do anything." In which order should the following nurse actions be done from first to last? a. Ask about the marital problems leading to the divorce b. Assess the clients risk for harm to self and others c. Obtain the name of her ex-husband's case manager d. Interview the client about her current needs and situation
b,d,c,a
A client who is newly diagnosed with paranoid schizophrenia tells the nurse, "the aliens are telling me that I am defective and need to be eliminated." Which of the following responses by the nurse is most appropriate initially? a. I know these voices are real to you, but I don't hear them b. You are having hallucinations as a result of your illness c. I want you to agree to tell staff when you hear these voices d. Your medications will help control these voices we are hearing
c
A client with chronic undifferentiated schizophrenia reports to the nurse that he does very little all day except sleep and eat. The nurse should: a. have three meals per day brought in to increase the amount of time the client spends out of bed. b. ask a relative to call the client at least 10 times a day to decrease the sleeping c. help the client set up a daily activity scheduled include setting a wake up alarm d. arrange for the client to move to a group home with structured activities
c
A suspicious client states, "I know you nurses are spraying my food with poison as you take it out of the cart." Which of the following actions would most likely be successful? a. Serving only foods that come in sealed packages b. Asking what kind of poison the client suspects is being used c. Giving the client canned supplements until the delusion subsides d. Allowing the client to be the first to open the cart and get a tray
d
When developing a plan of care for a client who is staying in his room because he perceives that staff wants to harm him, which of the following outcomes of care planning is most realistic? a. Within two days the client will complete his activities of daily living b. Within three days the client will participate in recreation with other clients c. Within four days the client will demonstrate an absence of verbal aggression d. Within five days the client will seek out staff to talk about feelings
d
