Psychotic Disorders Passpoint
During 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 am gone?" Which caregiver problem would be the most inclusive one for the nurse to incorporate into the client's plan of care? caregiver role strain disturbed sleep pattern anxiety fear
Correct response: caregiver role strain Explanation: The nurse recognizes the mother's feelings of being overwhelmed with the issues concerning the management of her daughter at home as caregiver role strain. Anxiety, fear, and sleep disturbances all contribute to caregiver role strain. The nurse should help the mother elicit the support of other family members or friends, continue with psychoeducation, and help the family connect with a support group.
The nurse is facilitating a group of clients with schizophrenia when one client says, "I like to drive my car, bar, tar, far." This client is exhibiting: neologisms echolalia. clang association. echopraxia.
Correct response: clang association. Explanation: Linking words together based on their sounds rather than their meanings is called clang association. Echolalia is the involuntary parrot-like repetition of words spoken by others. Echopraxia refers to meaningless imitation of others' motions. Neologisms are words that a person invents.
A nurse is caring for a client admitted with arching of the back, extension and rotation of the neck, and slow involuntary contractions of the arms and neck. After review of the client's medication list, the nurse would be correct in associating these symptoms with which medication? haloperidol pantoprazole propranolol benztropine
Correct response: haloperidol Explanation: Slow, involuntary contractions of the arms and neck, arching of the back, and extension and rotation of the neck are signs of dystonia. Dystonia is a common adverse effect of antipsychotic medications such as haloperidol. Benztropine is an antiparkinsonian drug, pantoprazole is an antiulcer medication, and propranolol is an antihypertensive.
When conducting a mental status examination with a newly admitted client who has a diagnosis of paranoid schizophrenia, the client states, "I'm being followed; it's not safe. They are monitoring my every move." In which area of the mental status examination should the nurse document this information? insight quality of speech thought content judgment
Correct response: thought content Explanation: The client is voicing paranoid delusions of being followed and monitored. Presence of delusions is described in the area of thought content in the mental status examination. The speech section would typically include documentation of disturbances in speech or pressured speech. In the insight section, the nurse would document information reflecting a lack of insight—for example, statements such as "I don't have a problem." In the judgment section, the nurse would document information reflecting a lack of judgment—for example, poor choices such as buying a gun for self-protection.
After several months of taking olanzapine, the client reports that he is no longer hearing voices of any kind. Which statement would confirm that the client is developing insight into his illness? "That olanzapine is the best medicine I have ever had." "My mom is proud of me for staying on my medicines." "I didn't realize how sick I could get from a chemical brain imbalance." "I think I may be able to get a little part-time job soon."
Correct response: "I didn't realize how sick I could get from a chemical brain imbalance." Explanation: Insight into the illness is demonstrated when the client recognizes the relationship between the chemical imbalance and his illness and symptoms. Stating that the olanzapine is the best medicine or that the client's mother is proud of him for staying on his medicines reflects awareness about the effect of medications and the need for compliance. Stating that he may be able to get a part-time job indicates an awareness of his increased capacity for work.
A client who is experiencing hallucinations asks if a nurse hears the voices saying that the client should never have been born. The nurse's most appropriate response would be: "Sometimes I hear voices. What are your voices saying?" "The voices are a symptom of your illness and will go away." "The voices are coming from inside you. They aren't real." "I don't hear any voices, but I believe you can hear them."
Correct response: "I don't hear any voices, but I believe you can hear them." Explanation: The nurse admitting to not hearing the voices but believing that the client can hear them is an honest, straightforward response that acknowledges the truth without negating the reality of the client's experience. The voices may be a symptom of the client's illness, but stating that negates the client's feelings and sense of reality. Although asking what the voices are saying provides an opportunity for the client to talk further, a nurse who makes this statement identifies too much with the client's hallucinations and gives them undue credibility. Stating that the voices aren't real discounts the client's experience of reality.
A client with schizophrenia states, "I hear the voice of King Tut." Which response by the nurse is therapeutic? "I don't hear the voice, but I know you hear what sounds like a voice." "King Tut has been dead for years, so that can't be his voice." "Does the voice sound like someone you know?" "You shouldn't focus on that voice; it is not real."
Correct response: "I don't hear the voice, but I know you hear what sounds like a voice." Explanation: This response makes a factual statement about the client's hallucination. Telling the client not to focus on the voice is judgmental. Telling the client not to worry because the voice is not real is a flippant, dismissive response. Saying "King Tut has been dead for years" is dismissive.
One of the clients in group with a dual diagnosis of chronic schizophrenia and alcohol abuse states, "I am not going to take medicine every day." Which response by the nurse would be most appropriate? "I hear you say that you don't like taking medication daily." "Let's discuss this tomorrow if we have time." "Your health care provider wants you to take your medication everyday." "Would anyone in group like to discuss this?"
Correct response: "I hear you say that you don't like taking medication daily." Explanation: By saying, "I hear you say that you don't like taking medication daily," the nurse accepts the client's statement so that the client feels heard and understood. The nurse demonstrates openness toward hearing unacceptable attitudes to foster further sharing among the clients. The other statements are not helpful or therapeutic. The client is ignored and dismissed, which can lead to increased anxiety, decreased self-esteem, and increased anger toward the nurse and other clients.
The nurse should judge client education regarding valproic acid as effective if the client states which statement? "I can take the valproic acid when I feel I need it." "Valproic acid is safe to use when I get pregnant." "I might need to take the valproic acid for a long time." "I can stop the valproic acid because the serum level is normal."
Correct response: "I might need to take the valproic acid for a long time." Explanation: Because bipolar disorder is a biochemical disorder, the client needs to know that she may need medication for a length of time.Stopping the valproic acid may cause a return of symptoms.Valproic acid is never prescribed on an as-needed basis. Careful regular dosing is needed to prevent toxicity, manage symptoms, and balance brain neurotransmitters.Valproic acid is not safe to take during pregnancy because of the risk to the fetus. The client should inform the nurse and healthcare provider if she thinks she might be pregnant.
The parent of a young adult client diagnosed with schizophrenia is asking questions about his son's antipsychotic medication, ziprasidone. Which statement by the parent reflects a need for further teaching? "If he becomes dizzy, I'll make sure he doesn't drive." "If he experiences restlessness or muscle stiffness, he should tell his health care provider." "I should give him benztropine to help prevent constipation from the ziprasidone." "The ziprasidone should help him be more motivated and less withdrawn."
Correct response: "I should give him benztropine to help prevent constipation from the ziprasidone." Explanation: Constipation caused by medication is best managed by diet, fluids, and exercise. Benztropine can increase constipation. However, it may be prescribed for restlessness and stiffness. Restlessness and stiffness should be reported to the health care provider (HCP). Drowsiness and dizziness are adverse effects of ziprasidone. Clients should not drive if they are experiencing dizziness. Ziprasidone does help improve the negative symptoms of schizophrenia such as avolition.
The nurse is caring for a client taking risperidone 2 mg daily. It is most important for the nurse to follow up on which client statement? "I take my medication every morning before breakfast." "I'm constantly sick and feel like I always have a fever." "Sometimes I get dizzy if I stand up quickly." "I've been exercising regularly and lost 5 pounds."
Correct response: "I'm constantly sick and feel like I always have a fever." Explanation: A major adverse reaction of risperidone is agranulocytosis. Therefore, it is a priority for the nurse to follow up if the client reports constantly being sick. Risperidone can be given without regard to meals; taking it at the same time every day is encouraged. Clients are encouraged to exercise regularly; the nurse should monitor the client taking risperidone for weight gain. Orthostatic hypotension is a common side effect of risperidone, and the nurse should follow up; however, the priority concern is agranulocytosis. Additionally, the client indicates experiencing dizziness "sometimes" but the feeling sick "constantly."
The nurse recognizes the client in the emergency department from a picture in the local paper. The client has recently received a major scholarship for high academic achievement. The client tells the nurse that he hears voices that tell him he is worthless. He has tried to kill himself. What statement is the most appropriate for the nurse to use first when attempting to establish a therapeutic relationship? "Would you like me to call your parents?" "You have a lot to live for." "I'm sorry this is happening to you." "The voices are not real."
Correct response: "I'm sorry this is happening to you." Explanation: Demonstrating empathy is an effective means of beginning an effective therapeutic relationship. Challenging the client's beliefs or thoughts is not the most effective in establishing a trusting relationship. Determining what supports are needed is done after an initial assessment.
During an extremely busy shift on the psychiatric unit, a newly graduated nurse approaches the charge nurse and states, "I'm having a hard time taking care of mentally ill people. What can I do to handle this stress?" What is the best response by the charge nurse? "Maybe you should attend some stress-reduction courses." "Maybe we could schedule a time to discuss this further." "Just ignore situations you can't change." "Try to take some deep breaths whenever you feel anxious."
Correct response: "Maybe we could schedule a time to discuss this further." Explanation: Suggesting to set a time for a more detailed discussion acknowledges that the charge nurse is concerned about what the new graduate said and provides an opportunity to explore and address the problem at a more appropriate time. Telling the new nurse to breathe deeply when feeling anxious doesn't help address the underlying issue. Although stress-reduction courses may ultimately prove useful, suggesting them at this time is impersonal and doesn't respond to the nurse's needs. Telling the new nurse to ignore situations can't be changed discounts the fact that the new nurse has identified a problem and is seeking an answer.
A client with bipolar disorder, manic phase, begins to swear at the nurse when reminded to limit telephone calls to 10 minutes. Which response should the nurse make? "Stop! Swearing is not appropriate behavior." "You know better than to use that language." "You need to act like an adult." "Others can hear you."
Correct response: "Stop! Swearing is not appropriate behavior." Explanation: The nurse sets limits on unacceptable or threatening behavior to help the client regain control and preserve his self-esteem. Saying, "You need to act like an adult," is an authoritarian comment that shames the client and diminishes self-esteem. Saying, "You know better than that," shames the client and diminishes self-worth. Saying, "Others can hear you," is not helpful because it does not identify the unacceptable behavior.
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 statement by the mother indicates that she understands her daughter's illness and management? "I know that I'll have to do everything for my daughter when she comes home." "Tasks as simple as getting out of bed and showering in the morning may be difficult for her." "I know that visits from her friends at home should be discouraged for a while." "She won't experience a relapse as long as she takes her prescribed medication."
Correct response: "Tasks as simple as getting out of bed and showering in the morning may be difficult for her." Explanation: Clients with paranoid schizophrenia experience alterations in thought resulting in introspection, confusion, and distraction from external reality. Simple tasks that require concentration and effort, including activities involving self-care, may be difficult for the client, especially during the acute phase of the illness. However, the mother should not need to do everything for her daughter. Rather, the mother should encourage the daughter to do things for herself with guidance. Visits from friends should be discussed with the client, and the client should be encouraged to visit with friends to minimize the risk of social isolation. Although relapse typically occurs with medication noncompliance, vulnerability to stress, a low threshold for stress, the number of stresses, and the client's lack of adaptive coping behaviors contribute to relapse.
A client tells a nurse that people from Mars are going to invade the Earth. Which response by the nurse would be therapeutic? "There are no people living on Mars." "I know you believe the Earth is going to be invaded, but I don't believe that." "What do you mean when you say they're going to invade the Earth?" "That must be frightening to you. Can you tell me how you feel about it?"
Correct response: "That must be frightening to you. Can you tell me how you feel about it?" Explanation: This response addresses the client's underlying fears without feeding the delusion. Refuting the client's delusion would increase anxiety and reinforce the delusion. Asking the client to elaborate on the delusion would also reinforce the delusion. Voicing disbelief about the delusion wouldn't help the client deal with the underlying fears.
Which concept is most important for a nurse to communicate to a client preparing to sign an informed consent for electroconvulsive therapy (ECT)? "You'll be offered a strong sedative before the procedure." "You may experience a time of confusion after the treatment." "You may experience a complete loss of memory after the treatment." "This therapy will provide excellent symptom relief."
Correct response: "You may experience a time of confusion after the treatment." Explanation: The nurse should explain that the client may experience a time of confusion following ECT as a result of electricity passing through the cerebral cortex and disrupting nerve impulses. Although it's true that the client will be offered a sedative, communicating this information isn't an essential component of informed consent. It's unrealistic to promise a client that the procedure will provide symptom relief. Complete memory loss isn't an expected response to ECT.
A newly admitted client diagnosed with paranoid schizophrenia is pacing rapidly and wringing his hands. He states that another client is out to get him. Then he says, "Protect me, select me, reject me." What should the nurse do next? Call the health care provider (HCP) for a prescription for restraints. Administer his oral PRN lorazepam and haloperidol. Ask the other clients to leave the immediate area. Place the client in temporary seclusion.
Correct response: Administer his oral PRN lorazepam and haloperidol. Explanation: The client's anxiety as reflected in rapid pacing and clang associations is rising as a result of his paranoid delusions. Administering the lorazepam and haloperidol will help the anxiety and delusions. The client is not threatening others at this point, so seclusion, restraints, and asking clients to leave the area is not necessary.
A nurse is caring for a client with schizophrenia who experiences auditory hallucinations. The client appears to be listening to someone who isn't visible. The client gestures, shouts angrily, and stops shouting in mid-sentence. Which nursing intervention is appropriate? Ask the client to describe what the voices are saying while making it clear the nurse doesn't hear the voices. Ask another nurse to enter the room with you to be certain you are safe. Encourage the client to go to the client's room to experience fewer distractions. Approach and touch the client to get the client's attention.
Correct response: Ask the client to describe what the voices are saying while making it clear the nurse doesn't hear the voices. Explanation: By acknowledging that the client hears voices, the nurse conveys acceptance. By letting the client know that the nurse doesn't hear the voices, the nurse avoids reinforcing the client's hallucination. The nurse shouldn't touch a client with schizophrenia without advance warning. A hallucinating client may believe that the touch is a threat or act of aggression and respond violently. Being alone in the client's room encourages the client to withdraw and may promote more hallucinations. The nurse should focus on the client's feelings and the client's safety.
A client with paranoid schizophrenia is recently admitted to the psychiatric unit. The client is hesitant to eat the food provided and states "I know they poisoned this food before putting it on my plate." What is the priority nursing action? Bring the client food in unopened containers. Request a cannabinoid appetite enhance from the provider. Ask the client which poison is inside the food. Have the family bring in the client's favorite food.
Correct response: Bring the client food in unopened containers. Explanation: Clients with paranoid schizophrenia are often concerned about the safety of their food. Bringing the client food in unopened containers may ease this paranoia. Because the client was recently admitted to the unit, requesting an appetite enhancer from the health care provider is not the priority action at this time. The nurse should attempt other strategies first. Having the family bring in food is passing the buck. The nurse should seek out strategies to help this client situation. Asking the client which poison is in the food is exploring the paranoia, which is not an appropriate nursing action.
A nurse is caring for a client receiving a dopamine receptor agonist for treatment of extrapyramidal symptoms caused by antipsychotic medications. What evaluation would indicate a therapeutic response to this drug? Client exhibits a shuffling gait with stooped posture. Client exhibits bradyphrenia during the nursing assessment. Client experiences a decrease in dystonia. Client exhibits akathisia only while sitting.
Correct response: Client experiences a decrease in dystonia. Explanation: Extrapyramidal effects and antipsychotic-induced muscle rigidity are caused by a low level of dopamine. Dopamine receptor agonists reduce extrapyramidal symptoms such as bradyphrenia or slowed thought processes, akathisia or meaningless movements such as marching in place, or dystonia or abnormal muscle rigidity or movements.
The client diagnosed with borderline personality disorder who is to be discharged soon threatens to "do something" to herself if discharged. What should the nurse do first? Ask a family member to stay with the client at home temporarily. Discuss the meaning of the client's statement with her. Request that the client's discharge be canceled. Ignore the client's statement because it is a sign of manipulation.
Correct response: Discuss the meaning of the client's statement with her. Explanation: Any suicidal statement must be assessed by the nurse. The nurse should discuss the client's statement with her to determine its meaning in terms of suicide, overwhelming feelings of anxiety, abandonment, or other need that the client cannot express appropriately. It is not uncommon for a client with borderline personality disorder to make threatening comments before discharge. Extending the hospital stay is inappropriate because it would encourage dependency and manipulation. Ignoring the client's statement on the assumption that it is a sign of manipulation is an error in judgment. Asking a family member to stay with the client temporarily at home is not appropriate and places the responsibility for the client on the family instead of the client.
A client is admitted with a diagnosis of schizophrenia. The client is paranoid and the student nurse asks the charge nurse about the approach to take with the client. The client has been exhibiting hostility and isolation. Which response by the student indicates understanding of the correct approach toward this client? Respect the client's need for personal space and avoid physical contact with the client. Inform the client that they are unwell and you will assist them. Greet the client by gently touching their arm, and telling the client they can trust you. Tell the client that if they do not comply with the rules, you will inform the doctor.
Correct response: Respect the client's need for personal space and avoid physical contact with the client. Explanation: A newly admitted client who is paranoid needs to have a sense of trust before the nurse attempts to touch the client. Touch is not therapeutic with someone who is suspicious. Using statements that imply the client is unwell or that potentially contain veiled threats will only increase the client's anxiety and lead to increased potential for hostility and anger.
The client diagnosed with borderline personality disorder who is to be discharged soon threatens to "do something" to herself if discharged. What should the nurse do first? Ignore the client's statement because it is a sign of manipulation. Request that the client's discharge be canceled. Discuss the meaning of the client's statement with her. Ask a family member to stay with the client at home temporarily.
Correct response: Discuss the meaning of the client's statement with her. Explanation: Any suicidal statement must be assessed by the nurse. The nurse should discuss the client's statement with her to determine its meaning in terms of suicide, overwhelming feelings of anxiety, abandonment, or other need that the client cannot express appropriately. It is not uncommon for a client with borderline personality disorder to make threatening comments before discharge. Extending the hospital stay is inappropriate because it would encourage dependency and manipulation. Ignoring the client's statement on the assumption that it is a sign of manipulation is an error in judgment. Asking a family member to stay with the client temporarily at home is not appropriate and places the responsibility for the client on the family instead of the client.
A client is in the withdrawn phase of catatonia due to schizophrenia. This is the client's first admission to an early psychosis program at an urban hospital. At present, the client is completely stuporous. What is the priority while giving care to the client during this phase of symptoms? Ask the client to do exactly the opposite of what is desired. Provide as much sensory stimulation as possible using conversation, radio, and television. Maintain a quiet atmosphere, speaking as little as possible to the client. Explain all physical care activities in simple, explicit terms as though expecting a response.
Correct response: Explain all physical care activities in simple, explicit terms as though expecting a response. Explanation: A client in a stuporous state is not in a position to negotiate, discuss, or gather insight. At this stage of a psychotic experience, a client requires clear and simple explanations of all activities. Not speaking much would be confusing and increase anxiety, but excessive information and stimuli would also not benefit goal-directed activities.
A client is admitted to the psychiatric emergency department with difficulty sleeping, poor judgment, and incoherent speech. The client reports being a special messenger from the Messiah who needs to be "sacrificed to save the world." Which action should the nurse take first? Institute suicide precautions. Ask a family member to stay with the client. Administer an oral antipsychotic. Encourage the client to describe the suicide plan.
Correct response: Institute suicide precautions. Explanation: Delusions of grandeur are common symptoms of the manic phase of bipolar disorder. The priority nursing action is to maintain client safety and institute suicide precautions. Administering an antipsychotic and asking about the suicide plan are acceptable nursing actions, but first the nurse must ensure client safety. Asking a family member to sit with the client inappropriately delegates responsibility to someone else; the nurse must address the issue of client safety immediately.
What should the nurse do when the client with a diagnosis of schizophrenia walks into group naked? Lead the client to his room and help him dress if he needs assistance. Instruct the client to go to his room and to put on some clothes. Ask a male client to take off his sweater and wrap it around the client's waist. Wrap a blanket around him and tell him to be seated for the remainder of group.
Correct response: Lead the client to his room and help him dress if he needs assistance. Explanation: The best nursing action is to lead the client to his room and assist him with putting on his clothes. The client with disorganized behavior needs the nurse's assistance to protect his self-esteem and dignity and to avoid embarrassment. Instructing the client to go to his room to put on his clothes may not be effective because the client may be too disorganized to follow directions. Wrapping a blanket around the client is helpful. Instructing him to be seated for the remainder of group is inappropriate and demeaning. Asking another client to remove his sweater and wrap it around the other client's waist is inappropriate.
The nurse is working in a community mental health clinic. A client who is diagnosed with schizophrenia is taking clozapine and reports of a sore throat. What is the most appropriate action for the nurse to take? Obtain an order for the client to have a white blood cell count drawn. Encourage the use of saline mouth rinses until the sore throat is gone. Suggest that the client drink warm beverages and rest. Have the client decrease the daily amount of clozapine by half.
Correct response: Obtain an order for the client to have a white blood cell count drawn. Explanation: The report of a sore throat may indicate an infection caused by agranulocytosis, a depletion in white blood cells. The way to determine this is by obtaining a white blood cell count. The other options do not get to the cause of the client's concern.
A client with a chronic mental illness has worked as a hotel maid for the past 3 years. She tells the nurse she is thinking of quitting her job because "voices on television are talking about me." What should the nurse do first? Check with the client's employer about her work performance. Obtain information about the client's medication compliance. Remind the client that hearing voices is a symptom of her illness that she can cope with. Arrange for the client to be admitted to a psychiatric hospital for a short stay.
Correct response: Obtain information about the client's medication compliance. Explanation: Symptom exacerbation is most often related to noncompliance with the prescribed medication regimen. Therefore, obtaining information about the client's compliance is the first priority. Helping the client recognize the symptoms and her ability to manage them is appropriate, but this is not the first priority. Checking with her employer is not appropriate and does not help the client with management of her illness. Hospitalization is not indicated because the client is still working and can talk about the symptoms.
A nurse is teaching a client about the prescribed drugs, chlorpromazine and benztropine. What evaluation would indicate a therapeutic response to these drugs? The client expresses a decrease in anxiety. The client does not report nausea and vomiting. The client displays akathisia while sitting. The client is experiencing less psychosis and a decrease in extrapyramidal symptoms.
Correct response: The client is experiencing less psychosis and a decrease in extrapyramidal symptoms. Explanation: Benztropine is an anticholinergic medication administered to reduce the extrapyramidal adverse effects of chlorpromazine and other antipsychotic medications. Benztropine doesn't reduce psychotic symptoms, relieve anxiety, or control nausea and vomiting. If the client displays akathisia or meaningless movements, this is not a therapeutic effect of the medication.
A nurse is teaching a client about the prescribed drugs, chlorpromazine and benztropine. What evaluation would indicate a therapeutic response to these drugs? The client is experiencing less psychosis and a decrease in extrapyramidal symptoms. The client displays akathisia while sitting. The client does not report nausea and vomiting. The client expresses a decrease in anxiety.
Correct response: The client is experiencing less psychosis and a decrease in extrapyramidal symptoms. Explanation: Benztropine is an anticholinergic medication administered to reduce the extrapyramidal adverse effects of chlorpromazine and other antipsychotic medications. Benztropine doesn't reduce psychotic symptoms, relieve anxiety, or control nausea and vomiting. If the client displays akathisia or meaningless movements, this is not a therapeutic effect of the medication.
A client is admitted to the psychiatric unit exhibiting extreme agitation, disorientation, and incoherence of speech with frantic and aimless physical activity and grandiose delusions. Which would the highest priority goal in planning nursing interventions? The client will show no self-harm or harm to staff. The client will be able to problem solve in situations on the psychiatric unit. The client will be free from anxiety and be able to use self-calming techniques before reaching panic level. The client will be oriented to person, place, and time.
Correct response: The client will show no self-harm or harm to staff. Explanation: The client is at increased risk for injury because of their hyperactivity, agitation, and disorientation. The goal for no self-harm or harm to staff best fits the priority for this situation. Although the client's anxiety and orientation is a concern and is important for the client's care, the client's safety always takes highest priority. The nurse should plan first and foremost to prevent injury and harm for which the client is at risk given their current condition.
The nurse is reviewing laboratory values of a client receiving clozapine. Which of the following laboratory values does the nurse immediately report to the health care provider (HCP)? hemoglobin of 11.9 g/dl (119 g/L) WBC of 3,500 hyaline casts in the urinalysis sodium level of 136 mEq/L (136 mmol/L)
Correct response: WBC of 3,500 Explanation: A side effect of clozapine is leukopenia. A WBC count is drawn every week and if it starts to drop, the HCP is notified. Slightly low hemoglobin levels or a normal sodium level are not significant. Hyaline casts occur because of protein in the urine, and a small amount is normally found in the urine, especially after exercise.
A client with chronic schizophrenia has received 10 mg of fluphenazine hydrochloride PO q.i.d. Now the client has a temperature of 102° F (38.9° C), a heart rate of 120 beats/minute, a respiratory rate of 20 breaths/minute, and a blood pressure of 210/140 mm Hg. Because the client is also confused and incontinent, the nurse suspects neuroleptic malignant syndrome. What steps should the nurse take? Give the client the next dose of fluphenazine and restrict the client to an empty room to decrease stimulation. Withhold the client's next dose of fluphenazine, administer an antipyretic agent, and increase the client's fluid intake. Withhold the client's next dose of fluphenazine, call the physician, and monitor the client's vital signs. Give the client the next dose of fluphenazine, call the physician, and monitor the client's vital signs.
Correct response: Withhold the client's next dose of fluphenazine, call the physician, and monitor the client's vital signs. Explanation: Neuroleptic malignant syndrome is a dangerous adverse effect of neuroleptic drugs such as fluphenazine. The nurse should withhold the next dose, notify the physician, and continue to monitor the client's vital signs. Although an antipyretic agent may be used to reduce fever, increased fluid intake is contraindicated because additional fluid may further increase the client's fluid volume, elevating the blood pressure even more.
The parents of a teenager recently diagnosed with schizophrenia ask the nurse about whether their other children will be susceptible as well. The nurse explains that schizophrenia is caused by: a combination of biological, psychologic, and environmental factors. genetic factors leading to a faulty dopamine receptor. environmental factors and childhood trauma. structural and neurobiological factors.
Correct response: a combination of biological, psychologic, and environmental factors. Explanation: A combination of biological, psychologic, and environmental factors is thought to cause schizophrenia. Studies of twins and adopted siblings have strongly implicated a genetic predisposition for schizophrenia; however, a reliable genetic marker has not been determined. Excessive dopamine activity in the brain has also been suggested as a causal factor. Communication and the family system have been studied as contributing factors in the development of schizophrenia.
The parents of a teenager recently diagnosed with schizophrenia ask the nurse about whether their other children will be susceptible as well. The nurse explains that schizophrenia is caused by: genetic factors leading to a faulty dopamine receptor. environmental factors and childhood trauma. structural and neurobiological factors. a combination of biological, psychologic, and environmental factors.
Correct response: a hallucination. Explanation: A hallucination is a sensory perception, such as hearing voices and seeing objects, that only the client experiences. A delusion is a false belief. Flight of ideas refers to a speech pattern in which a client skips from one unrelated subject to another. Ideas of reference refers to the mistaken belief that someone or something outside the client is controlling the client's ideas or behavior.
The nurse is planning care for a client who has been experiencing a manic episode for 6 days and is unable to sit still long enough to eat meals. Which choice will best meet the client's nutritional needs at this time? a peanut butter sandwich a bowl of vegetable soup a green salad topped with chicken pieces favorite foods from home
Correct response: a peanut butter sandwich Explanation: Giving the client finger foods that have protein, carbohydrates, and calories supplies energy and allows the client to eat while on the move. A salad or soup is very difficult for the client to eat while moving and may not supply the nutrients needed. Favorite foods from home may or may not be appropriate to eat while walking.
A client received haloperidol 12 hours previously. The client develops an oculogyric crisis and tongue protrusion. Which is a nursing priority intervention? administering chlorpromazine as ordered administering diphenhydramine as ordered administering diazepam as ordered administering midazolam as ordered
Correct response: 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.
An outpatient client who has a history of paranoid schizophrenia and chronic alcohol dependency has been taking risperidone for several months. She reports that she stopped drinking 4 days ago. The client is very frightened by the tactile hallucinations of bugs crawling under her skin. Which factor should the nurse incorporate into the plan of care when explaining the tactile hallucinations? alcohol intoxication ineffectiveness of risperidone alcohol withdrawal interaction of alcohol and risperidone
Correct response: alcohol withdrawal Explanation: Tactile hallucinations are more common in alcohol withdrawal than in schizophrenia. Therefore, the nurse should explain that these hallucinations are the result of withdrawal from alcohol. Because the client stopped drinking 4 days ago, the client is not intoxicated. Risperidone has little effect on symptoms of alcohol withdrawal. It is prescribed for symptoms of schizophrenia. Alcohol and risperidone have an additive effect, not one of causing hallucinations.
After 10 days of lithium therapy, the client's lithium level is 1.0. How does the nurse interpret this value? an atypical client response to the drug an anticipated therapeutic blood level of the drug a toxic level a laboratory error
Correct response: an anticipated therapeutic blood level of the drug Explanation: The therapeutic blood level range for lithium is between 0.6 and 1.2 for adults. A level of 1.0 can be anticipated after 10 days of treatment. Lithium toxicity occurs at levels above 1.5.While laboratory error can occur, that possibility would be more plausible if the level were extremely high or low.An atypical response would be manifested as an unusual physical or psychological response, not through blood levels.
After assessing the blood pressure of a client with a diagnosis of catatonia, the client's arm remains outstretched in an awkward position. Which of the following is the correct action by the nurse? Encourage client to reposition arm. Reposition the client's arm. Reposition the arm and apply wrist restraint. Keep arm in current position.
Correct response: avolition Explanation: Avolition refers to impairment in the ability to initiate goal-directed activity. Word salad is a behavior in which a group of words are put together in a random fashion without logical connection. A person exhibiting tangential behavior never gets to the point of the communication. In perseveration, a person repeats the same word or idea in response to different questions.
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 clozapine. The client tells the nurse that she has too much saliva and frequently needs to spit. The nurse interprets the client's statement as being consistent with which factor? unresolved symptom of schizophrenia expected adverse effect of clozapine delusion, requiring further assessment unusual reaction to clozapine
Correct response: expected adverse effect of clozapine Explanation: Excessive salivation, or sialorrhea, is commonly associated with clozapine therapy. The client can use a washcloth to wipe the saliva instead of spitting. It is an expected adverse effect of the drug, not a delusion, an unusual reaction, or an unresolved symptom of schizophrenia.
The client with borderline personality disorder spends much time around the nurse's station, making numerous minor requests. The nurse interprets these behaviors as indicating which factor? boredom suggesting the need for something to do fears of abandonment and attention seeking lack of desire for involvement in milieu activities enjoyment of bothering the staff
Correct response: fears of abandonment and attention seeking Explanation: Clients with borderline personality disorder have fears of abandonment and seek attention. Clients are dependent and fear being alone; this stems from disapproval, feelings of being abandoned, and not having needs met earlier in their life. The nurse intervenes by reducing attention-seeking behaviors and abandonment fears to help with intense feelings and emotions.
A client experiencing a schizophrenic episode is hospitalized. The client is attempting to hit and bite the staff. When the nurse phones the primary care provider for orders to help calm the client, the nurse anticipates what medication is likely to be ordered? chlorpromazine amitriptyline hydrochloride haloperidol lithium carbonate
Correct response: haloperidol Explanation: Haloperidol administered I.M. or I.V. is the drug of choice for acute aggressive psychotic behavior. Chlorpromazine is also an antipsychotic drug; however, it causes more pronounced sedation than haloperidol. Lithium carbonate is useful in bipolar disorder, and amitriptyline is used for depression.
A client with schizophrenia reports hearing the voices of the client's dead parents. To help the client ignore the voices, the nurse should recommend that the client: listen to a personal stereo through headphones and sing along with the music. sit in a quiet, dark room and concentrate on the voices. call a friend and discuss the voices and the client's feelings about them. engage in strenuous exercise.
Correct response: listen to a personal stereo through headphones and sing along with the music. Explanation: Increasing the amount of auditory stimulation (for example, by listening to music through headphones) may help the client focus on external sounds and ignore internal sounds from auditory hallucinations. Concentrating on the voices would make it harder for the client to ignore the hallucinations. Calling a friend to discuss the voices would encourage the client to focus on them. Exercise alone wouldn't provide enough auditory stimulation to drown out the voices.
A client diagnosed with paranoid personality disorder is hospitalized for physically threatening his wife because he suspects her of having an affair with a coworker. What approach should the nurse employ with this client? controlling parental authoritarian matter-of-fact
Correct response: matter-of-fact Explanation: For this client, the nurse needs to use a calm, matter-of-fact approach to create a nonthreatening and secure environment because the client is experiencing problems with suspiciousness and trust. Use of "I" statements and responses would be therapeutic to reduce the client's suspiciousness and increase his trust in the staff and the environment. An authoritarian approach is nontherapeutic and inappropriate because the client may perceive this approach as an attack, subsequently responding with anger and threatening behavior. A parental or controlling approach may be perceived as authoritarian, and the client may become defensive and angry.
A nurse is assigned to a client with catatonic schizophrenia. Which intervention should the nurse include in this client's care plan? providing a quiet environment in which the client can be alone administering lithium carbonate as ordered meeting all of the client's physical needs giving the client an opportunity to express concerns
Correct response: meeting all of the client's physical needs Explanation: Because a client with catatonic schizophrenia can't meet physical needs independently, the nurse must provide for all of these needs, including adequate food and fluid intake, exercise, and elimination. Although this client is incapable of expressing concerns, the nurse should try to verbalize the message the nonverbal behavior conveys. Lithium is used to treat mania, not catatonic schizophrenia. Despite the client's mute, unresponsive state, the nurse should provide nonthreatening stimulation and should spend time with the client, not leave the client alone all the time. Although aware of the environment, the client doesn't actively interact with it; the nurse's support and presence can be reassuring.
A client with schizophrenia displays a lack of interest in activities, reduced affect, and poor ability to perform activities of daily living. What term would be used to describe this clustering of symptoms? extrapyramidal symptoms negative symptoms positive symptoms physiologic symptoms
Correct response: negative symptoms Explanation: Schizophrenic clients commonly display positive and negative symptoms. Negative symptoms are characterized by the absence of typically displayed emotional responses. Clients with these symptoms tend to respond poorly to medication. Positive symptoms, such as auditory or visual hallucinations, are characterized by enhancement of a sensory modality. These aren't physiologic symptoms of schizophrenia. Extrapyramidal symptoms may result from long-term antipsychotic drug use in schizophrenics.
A client who's taking antipsychotic medication develops a very high temperature, severe muscle rigidity, tachycardia, and rapid deterioration in mental status. What complication of antipsychotic therapy does the nurse suspect? extrapyramidal effects neuroleptic malignant syndrome anticholinergic effects agranulocytosis
Correct response: neuroleptic malignant syndrome Explanation: Neuroleptic malignant syndrome is a rare but potentially fatal effect of antipsychotic medication. This condition generally begins with an elevated temperature and severe extrapyramidal effects. Agranulocytosis is a blood disorder. Symptoms of extrapyramidal effects include tremors, restlessness, muscle spasms, and pseudoparkinsonism. Anticholinergic effects include blurred vision, drowsiness, and dry mouth.
A client's nursing care plan includes the following prescription: "Assess for auditory hallucinations." What behavior would suggest to the nurse the client may be experiencing auditory hallucinations? poor eye contact, tilted head, mumbling to self performing rituals, avoiding open places distrust, fear, suspicion elevated mood, hyperactivity, distractibility
Correct response: poor eye contact, tilted head, mumbling to self Explanation: Cues that the client is experiencing auditory hallucinations include eyes looking around the room as though looking for a speaker, tilting the head to one side as though listening, and mumbling or talking aloud as though responding to someone. Performing rituals and avoiding open places is associated with anxiety and compulsive behaviors. Elevated mood and hyperactivity are features of a manic episode. Distrust and suspicion are prevalent in paranoia.
A client with schizophrenia tells the nurse, "My intestines are rotted from the worms chewing on them." This statement indicates a: delusion of grandeur. somatic delusion. jealous delusion. delusion of persecution.
Correct response: somatic delusion. Explanation: Somatic delusions focus on bodily functions or systems and commonly include delusions about foul odor emissions, insect infestations, internal parasites, and misshapen parts. Delusions of persecution are morbid beliefs that one is being mistreated and harassed by unidentified enemies. Delusions of grandeur are gross exaggerations of one's importance, wealth, power, or talents. Jealous delusions are delusions that one's spouse or lover is unfaithful.
A nurse is talking with a delusional client when the fire alarm sounds and a staff member closes the door to the client's room. The client becomes very agitated and declares, "The aliens have arrived!" Which actions are appropriate for the nurse to take? Select all that apply. staying with the client until the nurse receives further instructions telling the client that there's no danger and that everything's fine leaving the room but telling the client that the nurse will return soon telling the client that the alarm is just a drill and not to be afraid continuing to speak to the client in a reassuring tone
Correct response: staying with the client until the nurse receives further instructions continuing to speak to the client in a reassuring tone Explanation: After the client's physical safety is ensured, the client's most immediate need is emotional reassurance and safety. Therefore, it's best for the nurse to remain with the client and continue speaking with them in a reassuring tone of voice until the nurse receives further instructions. Assuring the client that everything is fine or that a fire drill is occurring may further agitate the client by invalidating their fear and attempting to appeal to logical thinking processes, which are impaired in a delusional client.
After working multiple shifts in the psychiatric intensive care unit, a nurse is becoming more distant and, at times, even irritable. The best action for the nurse to take would be to: request vacation time in order to achieve emotional restoration. continue to work and recognize that these feelings are normal. ask the charge nurse if another, less-demanding assignment is available. talk with the charge nurse and seek support from peers on the unit.
Correct response: talk with the charge nurse and seek support from peers on the unit. Explanation: Talking with the charge nurse and the nurse's own peers provides an opportunity for the nurse to express legitimate feelings and receive support and encouragement from others who understand. Although requesting vacation time may be helpful for the nurse in the short term, it isn't the best step to take. Requesting a less-demanding assignment is avoidant and doesn't address the nurse's feelings. Continuing to work without dealing with the feelings doesn't allow the nurse to provide the most therapeutic care to the clients. One of the most important factors in psychiatric nursing is self-knowledge.
When conducting a mental status examination with a newly admitted client who has a diagnosis of paranoid schizophrenia, the client states, "I'm being followed; it's not safe. They are monitoring my every move." In which area of the mental status examination should the nurse document this information? insight thought content quality of speech judgment
Correct response: thought content Explanation: The client is voicing paranoid delusions of being followed and monitored. Presence of delusions is described in the area of thought content in the mental status examination. The speech section would typically include documentation of disturbances in speech or pressured speech. In the insight section, the nurse would document information reflecting a lack of insight—for example, statements such as "I don't have a problem." In the judgment section, the nurse would document information reflecting a lack of judgment—for example, poor choices such as buying a gun for self-protection.
A client has been receiving chlorpromazine to treat psychosis. Which findings should alert the nurse that the client is experiencing pseudoparkinsonism? tremors, shuffling gait, and masklike face involuntary rolling of the eyes extremity and neck spasms, facial grimacing, and jerky movements restlessness, difficulty sitting still, and pacing
Correct response: tremors, shuffling gait, and masklike face Explanation: Pseudoparkinsonism may appear 1 to 5 days after starting an antipsychotic and may also include drooling, rigidity, and "pill rolling." Akathisia may occur several weeks after starting antipsychotic therapy and consists of restlessness, difficulty sitting still, and fidgeting. An oculogyric crisis characterized by uncontrollable rolling back of the eyes and, along with dystonia, should be considered a medical emergency. Dystonia may occur minutes to hours after receiving an antipsychotic and may include extremity and neck spasms, jerky muscle movements, and facial grimacing.
The health care provider prescribes risperidone 1 mg orally, two times a day for a client from a group home admitted to the hospital with severe antisocial behavior. The nurse determines that this dose is: too low for the client. too high for the client. typical when initiating therapy but it should be tapered down in 1 week. typical when initiating therapy.
Correct response: typical when initiating therapy. Explanation: Although medications are rarely effective in treating antisocial personality disorder, short-term use of antipsychotic medications may be helpful to decrease irritability and aggressive behavior. Treatment with risperidone typically begins with 1 mg twice a day for an adult and 0.5 mg twice a day for an elderly client. Dosage is increased, not tapered, over 1 week. Recommended dosages range from 4 to 6 mg/day.
A client with a diagnosis of schizophrenia is admitted to the psychiatric hospital in a catatonic state. During the physical examination, the client's arm remains outstretched after the nurse obtains pulse and blood pressure readings, and the nurse must reposition the arm. This client is exhibiting: negativity. retardation. suggestibility. waxy flexibility.
Correct response: waxy flexibility. Explanation: Waxy flexibility, the ability to assume and maintain awkward or uncomfortable positions for long periods, is characteristic of catatonic schizophrenia. Clients commonly remain in these awkward positions until someone repositions them. Clients with dependency problems may demonstrate suggestibility, a response pattern in which one easily agrees to the ideas and suggestions of others rather than making independent judgments. Catatonic clients may also exhibit negativity (for example, resistance to being moved or being asked to cooperate) and retardation (slowed movement).