psychotic disorders passpoint

Since admission 4 days ago, a client has refused to take a shower, stating, "There are poison crystals hidden in the showerhead. They'll kill me if I take a shower." Which action is most appropriate?

Accept the client's fears, allowing the client to take a sponge bath.

The nurse is caring for a client who has schizophrenia. What is the first-line treatment for this client?

Antipsychotics

A nurse is caring for a newly admitted client diagnosed with schizophrenia and is started on antipsychotic medication. When reviewing the client's file, which notation would alert the nurse to notify the health care provider before implementing?

Client is scheduled to have a myelogram within 48 hours of admission.

A 36-year-old client with a history of schizophrenia is admitted to the emergency department with a fever of 102° F (38.9° C), severe headache, photophobia, nuchal rigidity, and nausea. A physician believes that a lumbar puncture is necessary to help confirm his suspicions of meningitis. The nurse is asked to witness the informed consent. How can the nurse best assess the client's mental status before witnessing the consent?

Perform a brief mental status examination to determine whether the client is oriented to person, place, time, and purpose.

When reviewing a client's chart, the nurse sees the progress note. Which statement about the client's condition is most accurate?

The client may not be motivated to change their behavior or their lifestyle.

For several years, a client with chronic schizophrenia has received 10 mg of fluphenazine hydrochloride by mouth four times per day. 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 also is confused and incontinent, the nurse suspects malignant neuroleptic syndrome. What steps should the nurse take?

Withhold the next dose of fluphenazine, call the physician, and monitor vital signs.

A client with schizophrenia hears a voice telling him he is evil and must die. The nurse understands that the client is experiencing:

a hallucination.

A dopamine receptor agonist such as bromocriptine relieves muscle rigidity caused by antipsychotic medication by:

activating dopamine receptors in the CNS.

A nurse is implementing interventions for the care of a client admitted with a diagnosis of schizotypal personality disorder. Which behavior would the nurse most likely observe in the client during this situation?

paranoid thoughts

A client with depersonalization/derealization disorder spends much of the day in a dreamlike state, ignoring personal care needs. What situation is this behavior most likely related to?

perceptual impairment

An adolescent client with a diagnosis of schizophrenia has become very clingy and begins sucking their thumb while interacting with the nurse. The nurse understands that these behaviors indicate which defense mechanism?

regression

A client states, "I can't eat because my bowels have turned against me." The nurse determines that the client is exhibiting which behavior?

somatic delusion

A client with dissociative disorder is hospitalized. The client has threatened to commit suicide. When gathering data from the client, which set of circumstances would the nurse identify as indicating the highest risk of suicide?

suicide plan, handy means of carrying out plan, and history of previous attempt

A client with schizophrenia has been stable for some time. What action is most important for preventing relapse?

taking prescribed medications consistently

A client was hospitalized after a family member filed a petition for involuntary hospitalization for safety reasons. The family member seeks out the nurse because the client is angry and refuses to talk. The family member states, "I feel so guilty about my decision." Which response by the nurse is the most empathic?

"It's common for family members to feel this way. Can you tell me more?"

The nurse is gathering data from a client with dissociative identity disorder (DID). What statement by the client would the nurse expect to hear?

"I can't recall certain events or experiences."

A client with schizophrenia repeatedly uses profanity during an activity therapy session. Which response by the nurse would be appropriate?

"Your cursing is interrupting the activity. Take time out in your room for 10 minutes."

A client with a diagnosis of schizophrenia comments to the nurse, "How do I know what is really in those pills?" Which of the following is the appropriate response?

Allow him to open the individual wrappers of the medication.

A client with dissociative identity disorder (DID) requires hospitalization. Which intervention would most likely appear in the client's plan of care plan?

Arrange to have staff check on the client every 15 to 30 minutes.

A client is admitted to the emergency department frightened and reports hearing voices with instructions to do bad things. Which intervention should be the nurse's priority?

Assess the nature of the commands by asking the client what the voices are saying.

A nurse finds a suicidal client trying to hang themself with a belt. In order to preserve self-esteem and safety, what action should the nurse take?

Assign a nursing staff member to remain with the client at all times.

A client with delusional thinking is admitted to the mental health unit. He or she presently shows a lack of interest in eating. The client states, "I am unworthy of eating and if I eat, my children will die." Which nursing interventions are most appropriate for this delusional client? Select all that apply.

Divert the client's focus from unworthiness to reality. Do not agree with the client's delusion. Restrict the client's access to food except at specified meal and snack times.

A schizophrenic client states, "I hear the voice of King Tut." Which response by the nurse would be therapeutic?

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

A client tells the nurse that people from Mars are going to invade the earth. Which response by the nurse would be therapeutic?

That must be frightening to you. Can you tell me how you feel about it

Teaching for women in their childbearing years who are receiving antipsychotic medications should include which of the following facts?

The client should continue using contraception during periods of amenorrhea.

The nurse is reviewing a nursing care plan for a client with a psychophysiological disorder. Nursing interventions should address which symptoms?

physical symptoms as well as psychosocial and spiritual problems

A nurse is reviewing the interdisciplinary plan of care for a client experiencing hallucinations. Which intervention would the nurse most likely identify as being included in the plan?

providing a competing stimulus that distracts from the hallucinations

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:

talk with the charge nurse and seek support from peers on the unit.

A more experienced nurse is attempting to help a newly hired nurse gain a better understanding of delusions. Which statement, provided by the experienced nurse, would correctly explain behavior that represents a client's delusion?

"A client tells you that the FBI is monitoring conversations through their IUD (intrauterine device)."

A client is admitted to a mental health facility with delusions of grandeur. When collecting data from this client, which client statement would the nurse most likely hear?

"I have a special message from God about the end of the world."

A 45-year-old client with schizophrenia expresses a fear of sleeping because voices become threatening when she attempts to sleep. To avoid sleeping the client reports drinking 40 cups of coffee a day. Which response by the nurse is appropriate?

"I know that you're afraid to sleep; let's discuss the effect of caffeine on your voices."

The nurse reinforces the education provided to a client diagnosed with dissociative identity disorder (DID). The nurse determines that the client understands the need to continue therapy when the client makes which statement?

"I understand that I need to integrate all my alter personalities into one."

A client with schizophrenia becomes angry and tells the nurse to leave. Which response by the nurse would be best?

"I will leave now but will be back soon."

A client was the driver in an automobile accident in which a 3-year-old was killed; the client is now experiencing dissociative amnesia. After reviewing the treatment plan with the client, the nurse determines that the client demonstrates understanding by which statement?

"I'll attend my hypnotic therapy sessions prescribed by my psychiatrist."

While pacing in the hall, a client with schizophrenia runs to the nurse and says, "Why are you poisoning me? I know you work for central thought control! You can keep my thoughts. Give me back my soul!" How should the nurse respond during the early stage of the therapeutic process?

"I'm a nurse, and you're a client in the hospital. I'm not going to harm you."

The chart documentation of a client with paranoid personality disorder is listed below:10/151830The client stays by oneself as much as possible during the afternoon. The client paced the hallway at times and was irritated if approached by staff or other clients. The client questioned another male client and accused that client of lying. At the beginning of the shift the nurse spoke to the client accused of lying.Which statement, from the client accused of lying, would require further intervention?

"If I have an opportunity, I will not let him get away with this."

While interacting with a client with dissociative identity disorder (DID), a nurse observes characteristics of an alter personality. The client goes from being calm to being angry and shouting. Which response would be most appropriate?

"Tell me how you are feeling right now."

A client with dissociative amnesia says, "You must think I'm really stupid because I have no recollection of the accident." Which response would be most appropriate?

"The brain sometimes protects us by not letting us remember traumatic events."

Which concept is most important for a nurse to communicate to a client preparing to sign an informed consent for electroconvulsive therapy (ECT)?

"You may experience a time of confusion after the treatment."

A client is prescribed haloperidol. When reinforcing the teaching plan about the drug, which instruction would the nurse emphasize?

"You should report feelings of restlessness or agitation at once."

A 62-year-old male client with schizophrenia tells a nurse that he sexually molests his cousin. He tells the nurse that he's never told anyone and begs her to keep his secret. Which action should the nurse take?

Document the details of the conversation and notify the nursing supervisor.

The nurse is gathering data from a client with dissociative identity disorder (DID). What statement by the client would the nurse expect to hear

I can't recall certain events or experiences

A client with a history of schizophrenia is having hallucinations. The client shouts to the nurse, "You're stepping on spiders! Move aside. Don't you see them?" Which response by the nurse would be best?

I don't see them, but I know you believe you do

A 54-year-old client who was admitted to the psychiatric unit during an acute phase of schizophrenia has hardly eaten and hasn't bathed or changed his clothes for 3 weeks. He undergoes 4 weeks of psychotherapy and medication adjustment. Which statement by the client indicates that he's ready for discharge?

I know a sign of my disease is not bathing and maintaining my personal appearance

A nurse on a psychiatric unit observes a client in the corner of the room moving their lips as if they were talking to themselves. Which action is the most appropriate?

Invite the client to join in a card game.

The nurse is assigned to a client with schizophrenia who is experiencing catatonia. Which intervention should the nurse include in the client's plan of care?

Meeting all of the client's physical needs

The therapeutic team has identified the need to formulate strategies to maintain a safe environment for a client with schizophrenia displaying inappropriate behavior. Which strategy must be initiated immediately?

Monitor the client's behavior.

A client who's taking antipsychotic medication develops a very high temperature, severe muscle rigidity, tachycardia, and rapid deterioration in mental status. The nurse suspects what severe complication of antipsychotic therapy?

Neuroleptic malignant syndrome (NMS)

The nurse is caring for a schizophrenic client who becomes violent and delusional. Which therapeutic actions are best? (Select all that apply.)

Obtain additional staff assistance as needed. Ensure the safety of the client and others in the area. If restraints are required, explain what is being done and why.

A nurse is interacting with a client with a dissociative identity disorder. During the interaction, the nurse observes that one of the alter personalities is in control. Which intervention is most appropriate?

Recognize the alter personality.

During a conversation with a client, the nurse recognizes a delusion of persecution. What is the priority action by the nurse?

Redirect the conversation back to reality.

A registered nurse is caring for a group of clients on a psychiatric unit. Which task can the nurse delegate to the licensed practical/vocational nurse?

Redressing lacerations on the wrists of a client who attempted suicide.

A client has followed an antipsychotic medication regimen for a number of years. The health care provider treats a urinary tract infection with antibiotic therapy. Which action would be most appropriate?

Reinforce instruction on the medication, possible adverse effects, and a return demonstration for teaching effectiveness.

A nurse observes that an alternate personality (a child) of an adult client with dissociative identity disorder (DID) is in control. The client is sitting in the dayroom, interacting with others. Which action would be most appropriate?

Remove the client from the dayroom and reorient in a safe place.

A client in the behavioral health unit with a history of noncoercive paraphilia is experiencing an auditory hallucination. What is the priority nursing action?

Stay with the client

The nurse is preparing to administer chlorpromazine to a client with schizophrenia. Which circumstance, noted in the client's history, would cause the nurse to notify the health care provider for accuracy of the prescription?

The client is also receiving labetalol.

A nurse is caring for a client hospitalized in a behavioral health unit with disturbed thought process. What behavior by the client demonstrates resolution of the acute phase of the disorder?

The client's thoughts are reality-based with a decrease in delusions.

A client who is preparing for discharge to a halfway house must be referred to an outpatient clinic. Which criteria should be considered when choosing an outpatient treatment program for this client?

The clinic is within walking distance, and a staff member will send a caseworker to the halfway house to assess the client and develop a treatment plan.

While reading a journal article, a nurse comes across a discussion of the causes of dissociative disorders. Which information would the nurse most likely find in the discussion?

They occur as a result of the brain trying to protect the person from severe stress.

A nurse caring for a client diagnosed with schizophrenia should perform which intervention when the client becomes suspicious and refuses to take their medication?

Wait for a short time and then attempt to administer the medication

A client is being treated at a community mental health clinic. A nurse has been instructed to observe for any behaviors indicating dissociative identity disorder (DID). Which behavior would be included?

changes in dress, mannerisms, and voice

A client is referred to a mental health clinic by the court for harassing a couple next door and claiming that the husband was in love with her. She wrote love notes and called him on the telephone throughout the night. The client is employed and has had no problems with her job. The nurse interprets these findings as suggesting which condition?

delusional disorder

A client has just been diagnosed with dissociative identity disorder (DID). When implementing the plan of care for the client, the nurse would initially assist the client in achieving which goal?

determining what is causing the client to feel periods time are lost

A client is admitted to the psychiatric unit with active psychosis. The physician diagnoses schizophrenia after ruling out several other conditions. Schizophrenia is characterized by:

disturbances in affect, perception, and thought content and form.

A client is admitted with acute exacerbation of schizophrenia. The nurse anticipates that which therapy will most likely be initiated?

drug therapy to reduce symptoms associated with acute schizophrenia

A client with a history of bipolar disorder came to the hospital with an exacerbation. The client has been prescribed lithium and has not taken it for the past 2 weeks. What finding is the nurse likely observe?

flight of ideas

A nurse is collecting data from a client diagnosed with schizophrenia. Which symptoms would the nurse identify as supporting the client's diagnosis?

hallucinations or delusions and decreased ability to function in society

A client diagnosed with schizophrenia several years ago tells the nurse about feeling "very sad." The nurse observes that the client is smiling when saying it. When documenting this observation, the nurse would describe it using which term?

inappropriate affect

A client with schizophrenia tells the nurse he hears the voices of his dead parents. To help the client ignore the voices, the nurse should recommend that he:

listen to a personal stereo through headphones and sing along with the music.

The nurse is caring for a client diagnosed with schizophrenia. The client says, "The earth and the roof of the house rule the political structure with particles of rain." The nurse interprets this statement as which type of expression?

loose association

A nurse is carrying out the plan of care developed for a client diagnosed with dissociative identity disorder (DID). Which intervention would be the priority for this client?

maintaining consistency when interacting with the client

The nurse is reviewing the plan of care for a client diagnosed with schizophrenia who has just been admitted to the psychiatric unit. Which intervention would the nurse identify as the priority for this client?

providing a consistent, predictable environment

A client with dissociative identity disorder (DID) is admitted to an inpatient psychiatric unit. A nurse-manager asks all staff to attend a meeting. Which is the most likely reason for the meeting?

to allow staff members to discuss concerns about working with a client with DID

During data collection, a client with schizophrenia leaves his arm in the air after the nurse has taken his blood pressure. His action shows evidence of

waxy flexibility

A client is admitted to the psychiatric hospital with a diagnosis of schizophrenia and who is experiencing catatonia. During the physical examination, the client's arm remains outstretched after the nurse obtains the pulse and blood pressure, and the nurse must reposition the arm. This client is exhibiting:

waxy flexibility.