BPS3 NCLEX Questions
E. Thought blocking Major Takeaway Thought blocking, classically seen in schizophrenia, is a phenomenon where a person frequently pauses, loses train of thought, and begins talking about completely unrelated topics at unexpected times. Main Explanation This is a classic presentation of thought blocking, a commonly observed phenomenon in patients with mental illnesses, particularly schizophrenia. Thought blocking is a thought disorder where a person's train of thought suddenly ceases, there is a pause, and they randomly initiate conversation on completely unrelated topics. During the pause, which can last seconds to a few minutes, some patients have described the phenomenon as a complete cessation of cognition or a complete and unexpected emptying of the mind. Sometimes, this phenomenon is attributed by the patient to their delusions or hallucinations. For example, a patient may say a spirit or another person is stealing his/her thoughts.
A 26-year-old Caucasian woman is brought to the office for a follow-up evaluation of her mental status and cognitive functioning. Her medical history is relevant to schizophrenia. Upon medical interrogation, the patient frequently loses her train of thought, makes long pauses, and begins talking in the middle of sentences about completely unrelated topics. On physical examination, the patient knows her name and responds in a meaningful manner to verbal instructions or gestures. Before finishing the exam she comments about how beautiful the office is. Which of the following best describes the phenomenon being observed in this patient? A. Dementia B. Disorientation C. Dissociative fugue D. Log rolling E. Thought blocking
D. Obsessive compulsive personality disorder Major Takeaway Obsessive compulsive disorder is characterized by obsessive thoughts that provoke anxiety, which is relieved by performing a compulsion. In contrast, patients with obsessive compulsive personality disorder are in harmony with their personality, and enjoy following their own rules for order. Main Explanation This patient has obsessive compulsive personality disorder (OCPD). The main difference between obsessive compulsive disorder (OCD) and OCPD is the type of impulse a patient experiences. Patients with OCPD are in harmony with their personality. An example would be a patient who likes things in alphabetical order and makes sure all of their books and work materials are kept in that manner as described in this question stem. OCPD is a life long pattern with the person strictly following their own rules. Conversely, OCD patients recognize they have a problem and want a solution. The condition is characterized by obsessive thoughts that provoke anxiety, which is relieved by the compulsion. For example, anxiety from an obsession about not leaving the front door open is relieved by locking the front door many times each day. The patient realizes that the behavior is excessive, but cannot help it. There are abnormalities in serotonin metabolism in patients with OCD, and hence the treatment of choice is selective serotonin reuptake inhibitors.
A 34-year-old man comes to the office for a follow up appointment. He tells you that he is doing well, except that he seems to be spending most of his time organizing various things around his house. He states that in the last week, he has organized his bookshelf, his kitchen, and has color-coded his wardrobe. He enjoys doing these tasks but states that there seems to be no end to his organizing. He states he has always been this way, and that when his possessions are not organized, he gets very frustrated. His symptoms have affected his ability to maintain relationships with his family and friends. Which of the following is the most likely diagnosis? A. Generalized anxiety disorder B. Normal behavior C. Obsessive compulsive disorder D. Obsessive Compulsive Personality Disorder E. Depression
E. Risperidone Major Takeaway Risperidone is an atypical antipsychotic commonly used to treat schizophrenia, a psychotic disorder characterized by hallucinations, delusions, and abnormal social functioning. Main Explanation This scenario illustrates an individual with a primary psychotic disorder, likely schizophrenia. The Schneiderian First-Rank Symptoms of schizophrenia include: Auditory hallucinations Third person Running commentary Hearing thoughts spoken aloud Delusional perception Passivity phenomena Somatic passivity Actions influenced by external agents Thought withdrawal Thought insertion Thought broadcast Risperidone is an atypical antipsychotic commonly used to treat schizophrenia. It is notably useful in treating the patient's present symptoms of paranoid delusions and auditory hallucinations. Common side effects are weight gain, postural hypotension, drowsiness and extra pyramidal side effects.
A 35-year-old man comes to the inpatient psychiatric ward because of psychosis. He was admitted because he thinks his neighbors are spying on him and devising ways to kill him. He says they have inserted cameras in several rooms of his house to monitor his activities. He claims to hear them through the walls saying they are "going to get him". The patient's wife called the police when he bought a gun stating that he was going to wait for them to come. Which of the following is the most appropriate pharmacologic treatment in this patient? A. Benztropine B. Diazepam C. Fluoxetine D. Lithium E. Risperidone
E. Tardive dyskinesia Major Takeaway Tardive dyskinesia is characterized by repetitive, involuntary, purposeless movements that can include lip smacking, pursing of the lips, tongue movements, and grimacing. They develop after years of treatment with typical antipsychotics (typical>atypical), especially haloperidol. Clozapine, an atypical antipsychotic, is least likely to cause tardive dyskinesia. Main Explanation The patient has classic signs of tardive dyskinesia, a neurological condition characterized by involuntary movements of the tongue, lips, face, trunk, and extremities. It most often occurs in patients undergoing long-term (>3 months) or high-dose treatments of antipsychotic medications - most notably dopaminergic antagonists. Neuroleptic-induced tardive dyskinesia is characterized by choreiform, athetoid, and rhythmic movements of the tongue, jaw, trunk, and extremities that have persisted for at ≥4 weeks and that began during treatment with neuroleptics or within 4 weeks of discontinuing neuroleptics. Diagnosis of neuroleptic-induced TD generally requires exposure to neuroleptics for at ≥3 months. At least a month of exposure is typically required if the patient is aged 60 years or older. There is no effective treatment. Typical antipsychotics are more likely to cause tardive dyskinesia compared to atypical antipsychotics. If patients are particularly concerned about tardive dyskinesia, clozapine is the antipsychotic with the least likelihood of inducing the condition.
A 75-year-old woman comes to the clinic for a routine check-up. She has a long history of schizophrenia, requiring antipsychotic treatment on many various agents including risperidone and haldol. She denies a history of depression, suicidal ideation, homicidal ideation, or illicit drug use. Physical examination shows involuntary chewing movements, lip smacking, and grimacing. She says these symptoms may have started about 2 months ago, but she thought it was just a sign of old age. Which of the following is the most likely diagnosis? A. Acute dystonia B. Akathisia C. Athetosis D. Parkinsonism E. Tardive dyskinesia
4 The priority nursing action is to explore the content of the hallucinations. This client may be experiencing command auditory hallucinations that could lead to self-directed or other-directed injury and harm. After the content of the hallucinations has been explored, implementing an intervention may be necessary to reduce the potential for violence. Hallucinations are false sensory perceptions that have no external stimuli. They can occur in any of the 5 senses. Auditory hallucinations are the most common, followed by visual, tactile (touch), olfactory (smell), and gustatory (taste). Additional ways to deal with hallucinations include the following: Telling the client that you know they are real to the client but that you do not hear the voices (or see the vision, feel the sensation) Not arguing with or challenging the client about the hallucinations Directing the client to a reality-oriented topic of conversation or activity (Option 1) An antianxiety medication may be needed if the voices are causing this client to become increasingly distressed. Assessment is needed before choosing this option. (Option 2) This choice dismisses this client's concerns about the nature of the voices. (Option 3) Telling the voices to "go away" (voice dismissal) is a technique that some clients find effective in management of hallucinations. It is not the priority nursing action in this client.
A client recently diagnosed with schizophrenia is hospitalized. The client appears distraught and says to the nurse, "The voices are bad today...they are so angry with me." Which of the following is the best response by the nurse? 1. "Do you need something to help you calm down?" 2. "Don't pay any attention to the voices. Let's go into the dayroom." 3. "The voices are not real. Tell them to go away." 4. "What are the voices saying to you?"
3 The client may act on command hallucinations and harm himself or others. Therefore, the staff needs to know when the client is hearing such commands, to ensure safety first. Telling the client that the voices are real but that the nurse does not hear them would be an appropriate response later in the client's hospitalization when the client's safety is no longer an issue because antipsychotics are beginning to take effect. Telling the client that the hallucinations are part of the illness or that medications will help control the voices would be appropriate once the client has developed some insight into the symptoms of illness.
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 response by the nurse is most appropriate initially? 1. "I know those voices are real to you, but I do not hear them." 2. "You are having hallucinations as a result of your illness." 3. "I want you to agree to tell staff when you hear these voices." 4. "Your medications will help control these voices you are hearing."
2 The client, while delusional, is exhibiting signs of anxiety. The priority action for the nurse is to intervene in a manner that will assist in reducing the client's unease. The headband is part of the client's delusional system; it is highly likely that the client will continue to be apprehensive until the headband or substitute is found. Offering to help the client look for the headband conveys a sense of caring and helps establish a trusting relationship. Once the client has calmed down, the nurse will minimize any conversation about the "crack" and the "oil" and can direct the client to reality-oriented activities. Delusions are fixed, false beliefs that are accepted by the client as real and cannot be changed by logic, reason, or persuasion. Categories of delusions include the following: Persecutory - client thinks others are "out to get me" Ideas of reference - common events refer specifically to the client Grandiose - client has the perception of special importance or powers that are not realistic Somatic - false ideas about bodily functioning Nursing interventions include the following: Not arguing or challenging the belief Reinforcing reality by talking about and encouraging the client to participate in real events. The nurse should not delve into or have long conversations about the delusional belief system. (Option 1) This response focuses on the delusional content and is not therapeutic. It does not help alleviate the client's anxiety. (Option 3) Challenging the delusional content is not therapeutic and will not change the client's belief. (Option 4) This statement does not help reduce the client's anxiety.
A client with a 20-year history of schizophrenia is hospitalized. The client appears visibly upset, approaches the nurse, and says in a shaky voice, "I can't find my headband. I can't find my headband. The oil is going to leak out of the crack in my head." What is the best response by the nurse? 1. "How long has the oil been leaking from your head?" 2. "Let's go back to your room and look for your headband together." 3. "There is no oil coming out of your head." 4. "You are going to miss breakfast if you do not go into the dining room."
3. A diagnosis of schizophrenia with catatonia can be made if the clinical features meet the criteria for a diagnosis of schizophrenia and include at least 2 of the following additional features: Immobility—the client remains in a fixed stupor or position for long periods Refuses to move about or engage in activities of daily living May have brief spurts of excitement or hyperactivity Remaining mute Bizarre postures—the client holds the body rigidly in one position Extreme negativism—the client resists instructions or attempts to be moved Waxy flexibility—the client's limbs stay in the same position in which they are placed by another person Staring Stereotyped movements, prominent mannerisms, or grimacing Clients with catatonic schizophrenia are unable to meet their basic needs for adequate fluid and food intake and are at high risk for dehydration and malnutrition. The priority nursing action is to anticipate the client's needs, and to ensure that the client is well hydrated and has adequate nourishment. Some clients will need total care. (Option 1) Impaired social interaction is also an appropriate nursing diagnosis in a client with catatonic schizophrenia. However, it is not a priority, especially during the early phases of the disease. (Option 2) The client's mutism makes the diagnosis of impaired verbal communication appropriate, and the nurse should gently encourage this client to talk without undue expectations or pressure. This is not the priority nursing diagnosis. (Option 4) If this client is in a bizarre or fixed posture, there may be a risk for decreased circulation and pressure ulcers. The nurse needs to encourage ambulation and/or provide range-of-motion exercises.
A client with a diagnosis of schizophrenia with catatonia has recently been admitted to the psychiatric unit. Which of the following is the priority nursing diagnosis? 1. Impaired social interaction 2. Impaired verbal communication 3. Risk for deficient fluid volume 4. Risk for impaired skin integrity
Clients have the right to refuse hospital admission and treatment under the Fourteenth Amendment to the United States Constitution, which guarantees protection against loss of liberty. However, all states have laws and procedures for involuntary commitment that require clients to receive inpatient treatment for a psychiatric disorder against their will. The legal criteria for involuntary commitment include the following: The individual appears to be an imminent danger to self or others and Grave disability - as a result of a mental illness, the person is unable to adequately care for basic needs, including food, clothing, shelter, medical care, and personal safety Clients also have the right to the least restrictive environment in which treatment can be provided in a safe manner. Involuntary commitment is generally used as a last resort in dealing with a client whose illness is so severe that judgment and insight in deciding to refuse treatment are markedly impaired. (Option 1) Refusing to cooperate with the treatment plan is not a criterion for involuntary commitment. Clients have the right to refuse treatment. (Option 3) A roommate is not an appropriate surrogate decision maker to give consent. The spouse, children, or parents are usually contacted when clients are not able to give consent. (Option 4) The diagnosis of a mental illness alone does not justify the need for involuntary commitment.
A college student finds a roommate mumbling and huddling in the corner of the room. The student brings the roommate to the emergency department, where the roommate is tentatively diagnosed with schizophrenia. The treatment plan includes hospitalization on the acute psychiatric unit and initiation of anti-psychotropic medication therapy. The client refuses to be admitted. Which of the following statements about hospital admission is true for this client? 1. If the client refuses to cooperate with the treatment plan, the client can be involuntarily committed. 2. If the treatment team determines the client poses danger to self or others, the client can be involuntarily committed. 3. The client can be involuntarily committed for observation and treatment if the roommate can provide consent. 4. The diagnosis of schizophrenia alone justifies the need for involuntary commitment.
4 Clozapine is an antipsychotic medication. Clients taking clozapine can experience hematological adverse effects, including agranulocytosis and mild leukopenia. The white blood cell count should be assessed before initiation of treatment and should be monitored closely during the use of this medication. The client also should be monitored for signs indicating agranulocytosis, which may include sore throat, malaise, and fever. The remaining options are unrelated to this medication.
A hospitalized client is receiving clozapine for the treatment of schizophrenic disorder. The nurse determines that the client may be having an adverse reaction to the medication if abnormalities are noted on which laboratory study? 1. Platelet count 2. Cholesterol level 3. Blood urea nitrogen 4. White blood cell count
1 The avoidant personality disorder is characterized by social withdrawal and extreme sensitivity to potential rejection. The person retreats to social isolation. Borderline personality disorder is characterized by unstable mood and self-image and impulsive and unpredictable behavior. Schizotypal personality disorder is characterized by the display of abnormal thoughts, perceptions, speech, and behaviors. Obsessive-compulsive personality disorder is characterized by perfectionism, the need to control others, and a devotion to work.
A patient is unwilling to go to his church because his ex-girlfriend goes there and he feels that she will laugh at him if she sees him. Because of this hypersensitivity to a reaction from her, the client remains homebound. The home care nurse develops a plan of care that addresses which personality disorder? 1. Avoidant 2. Borderline 3. Schizotypal 4. Obsessive-compulsive
4. The therapeutic response by the nurse is the one that clarifies the content of the client's statements and directs the client to the purpose of the session. The nurse should confront the client verbally regarding the inappropriate statements and refocus the client back to the issue of the session. Avoid options that may be judgmental and may provide an opening for a verbal struggle, or those that are a social response and could be misinterpreted by the client.
During a therapy session a client with a personality disorder says to the nurse, "You look so nice today. I love how you do your hair, and I love that perfume you're wearing." Which response by the nurse would best address this breech of boundaries? 1. Your comment is really inappropriate 2. Thank you, the perfume was a gift. 3. Neither my hair nor my perfume is the focus of today's session. 4. The focus of today's session is on your issues, so let's get started.
2 Decreased need for sleep and racing thoughts are the most prominent hallmarks of mania. Feelings of pleasure, motivation, and increased energy, within reason, are desired experiences. Also, leaving a job to start a new business is not, in itself, a sign of impending illness.
In a pre-discharge program to educate clients with bipolar and their family members, the nurse emphasizes which symptom is the most significant indicator for the onset of relapse? 1. A sense of pleasure and motivation for new endeavors 2. Decreased need for sleep and racing thoughts 3. Self-concern about increase in energy 4. Leaving a good job to start a new business
1 A flat affect is manifested as an immobile facial expression or blank look. A blunted affect is a minimal emotional response or outward affect that typically does not coincide with the client's inner emotions. A bizarre affect, such as grimacing, laughing, and self-directed mumbling is marked when the client is unable to relate logically to the environment. An inappropriate affect refers to an emotional response to a situation that is incongruent with the tone of the situation.
The mental health nurse notes that a client diagnosed with schizophrenia is exhibiting flat affect. Which situation supports this documentation? 1. During the entire family visit, the client presented with an expressionless, blank look. 2. The client demonstrated minimal response to the news that his discharge had been postponed. 3. The client grimaced during the entire therapy session that focused on finding one's personal joy. 4. During grief therapy, the client was observed laughing while another client described the death of a parent.
1, 3, 4, 5 When caring for a client with paranoia, the nurse should ask permission if touch is necessary because touch may be interpreted as a sexual or physical assault. The nurse must eliminate any physical contact and not touch the client unless necessary and with the client's permission. The anger that a paranoid client expresses often is displaced, and when a staff member becomes defensive, both client and staff anger may escalate. Simple and clear language should be used in speaking to the client to prevent misinterpretation and to clarify the nurse's intent and action. The nurse should avoid a warm approach because warmth can be frightening to a person who needs emotional distance.
The nurse creating a plan of care for the client demonstrating paranoia should include which interventions int he plan of care? Select all that apply. 1. Ask permission before touching the client. 2. Provide a warm, social approach to the client. 3. Eliminate all unnecessary physical contact with the client. 4. Defuse any anger or verbal attacks with a nondefensive stance. 5. Use simple and clear language when communicating with the client.
3. Somatization disorder Somatization disorder is characterized by a long history of multiple physical problems with no satisfactory organic explanation. The clinical findings associated with schizophrenia, depression, and obsessive-compuslive personality disorder are unrelated to somatic complaints.
The nurse int he mental health unit is performing an assessment on a client who has a history of multiple physical complaints involving several organ systems. Diagnostic studies revealed no organic pathology. The care plan developed for this client will reflect that the client is experiencing which disorder? 1. Depression 2. Schizophrenia 3. Somatization disorder 4. Obsessive-compulsive personality disorder
3 It is important to distinguish clinically between the very similar presentations of intoxication, delirium secondary to a medical condition, dementia, and psychiatric disorders involving distorted perceptions of reality in order to begin the appropriate treatment. Some illicit substances (eg, marijuana, LSD, PCP) have been reported to cause episodes of severe, acute psychosis. Some clients will never experience another episode of psychosis. However, in rare cases, illicit substances may trigger a genetic predisposition to development of a mental illness. There is no way to establish the long-term prognosis. (Option 1) The long-term prognosis after an episode of psychosis is impossible to predict with any accuracy. It is tempting to offer comfort to a client's family in a time of crisis, but the nurse should never make promises. (Option 2) Most cases of drug-induced psychosis are transient. (Option 4) After substance abuse has been verified, client education regarding drug abuse and therapy or counseling are indicated. However, it is extremely unprofessional to judge clients for their behavior and lifestyle choices.
The nurse is caring for a client who entered the psychiatric emergency department in a state of acute psychosis after ingesting illicit substances. The parents ask the nurse if the client will develop schizophrenia. What is the most appropriate response by the nurse? 1. "I know it must be terrible to see your son like this, but he will be fine." 2. "Most people have permanent side effects after an episode like this." 3. "Your son will have to remain here for observation until we know more." 4. "Your son would be fine right now if he had not taken these drugs."
3 Distraction and disorganization may prevent clients from eating or sleeping. Monitoring for needed intervention can prevent exhaustion and malnutrition. Liquid medications are indicated only if the client cannot or will not swallow tablets. Manic clients tend to disrupt group therapy, so this treatment usually is not for them. Family visits should not be tied to compliance with treatment. The client is unlikely to be able to concentrate and complete a journal at this time.
The nurse is caring for a client with bipolar disorder who was recently admitted to an inpatient unit and is experiencing a manic episode. What is a priority nursing intervention for this client? 1. Order and administer all medications in a liquid form. 2. Base permission for family visits on the client's attendance to therapy groups. 3. Closely monitor the client's eating and sleeping patterns. 4. Encourage the client to keep a journal about feelings and emotions.
4. Attending an activity with the nurse assists the patient to become involved with others slowly. The patient with schizotypal personality disorder needs support, kindness, and gentle suggestion to improve social skills and interpersonal relationships. The patient commonly has problems in thinking, perceiving, and communicating, and appears similar to patients with schizophrenia except that psychotic episodes are infrequent and less severe. Participation solely in group activities or leading a sing-along would be too overwhelming for the patient, subsequently increasing the patient's anxiety and withdrawal. Engaging primarily in one-to-one activities would not be helpful because of the patient's difficulty with social skills and interpersonal relationships. However, activities with the nurse could be used to establish trust. Then, the patient could proceed to activities with others.
When planning care for a patient with schizotypal personality disorder, which intervention helps the patient become involved with others? 1. Participating solely in group activities. 2. being involved with primarily one-to-one activities. 3. leading a sing-along in the afternoon. 4. attending an activity with the nurse.
1 Clients often forget to take their medications as scheduled, and this is the most prominent problem since medication therapy is vital to the function of clients with such a diagnosis. While the situations described in the remaining options may occur, these problems are not as impacting on the client's prognosis and can be addressed and often controlled.
Which situation will present the most prominent problem to manage the outpatient care of a client diagnosed with schizophrenia? 1. The client's noncompliance with medication therapy 2. The community's opposition to outpatient mental health clinics 3. The associated increased risk that the client may become homeless 4. The family's negative reaction to transferring the client to community-based care?
