Mental health 11
A newly admitted client has the diagnosis of catatonic schizophrenia. The nurse would expect to assess: 1. Psychomotor symptoms 2. Intense suspiciousness 3. Inappropriate affect 4. Clanging communication
ANS: 1 Catatonic schizophrenia is characterized by extremes of psychomotor activity ranging from frenzied behavior to immobilization and may include echopraxia and posturing. Option 2: Paranoid thinking is characteristic of paranoid schizophrenia. Options 3 and 4. Inappropriate affect and clanging are seen in disorganized schizophrenia.
Because of the cognitive disturbances associated with schizophrenia, which technique will be useful as the nurse teaches a client about selfmanagement? 1. Teach material in small segments. 2. Use only verbal instruction. 3. Plan the teaching for a time when client is stimulated and busy. 4. Offer opportunities for making a large number of choices.
ANS: 1 Clients with cognitive disturbances should be taught small blocks of information at a time and given frequent reinforcement. Both verbal and visual materials should be used since processing of verbal stimuli may be more impaired. The client's symptoms should be relatively stable so that cognitive processing is maximized, and the teaching environment should be as free of extraneous stimuli as possible. A large number of choices may be confusing for the person, but a few simple choices may be included.
A client tried to gouge out his eye in response to auditory hallucinations commanding, "If thine eye offend thee, pluck it out." The nurse would analyze this behavior as indicating: 1. Impaired impulse control 2. Inability to manage anger 3. Derealization 4. Inappropriate affect
ANS: 1 Command hallucinations may be so intense that the client cannot control the impulse to do what the hallucination tells him to do; thus the client has impaired impulse control. 2. This is not an anger management problem. 3. Derealization is a feeling that the environment is distorted or unreal and not suggested in the scenario. 4. No evidence of inappropriate affect is given.
Sertraline (Zoloft) has been prescribed for a client with symptoms of a major depression. Which factor was probably most important in the physician's decision to use an SSRI? 1. Good side-effect profile 2. Less expense for the client 3. Increase in compliance 4. Rapid rate of absorption from the GI tract
ANS: 1 Compared to other antidepressant medication groups, SSRIs have the best side-effect profile. 2. SSRIs are more costly. 3. No studies have shown that SSRIs result in better compliance. 4. These drugs are absorbed slowly from the GI tract.
The wife of a client newly diagnosed with paranoid schizophrenia asks the nurse, "My husband was well adjusted until a month ago, and then, after a lot of work stress, he got sick. What can I expect? Will he be this sick for the rest of his life?" What information can the nurse provide about prognosis? 1. "This disorder responds well to treatment and, with followup, may not recur." 2. "All types of schizophrenia are chronic relapsing disorders." 3. "Outcomes are poor related to client prehospital disorganization." 4. "The usual outcome is that only partial remission is achieved."
ANS: 1 Option 1 is a true statement about the prognosis of paranoid schizophrenia. In certain instances, the client has been productive prior to the illness and has suffered severe stress that results in onset of illness. Good premorbid adjustment is a positive factor, suggesting a good prognosis. 2. This is not strictly the case. 3. This is truer of disorganized type schizophrenia. 4. This is truer of undifferentiated schizophrenia.
The nurse is assessing a client who will be having an orthopedic surgery. The client takes an antipsychotic medication and shares that he has recently started using two herbal preparations for his nerves. The nurse should: 1. Ask for the specific names of the herbal compounds 2. Go on to another interview question since herbal compounds are not important 3. Tell him to stop using the herbal preparations because they are not effective 4. Explain that his physician will not be happy with his selfprescribing
ANS: 1 Some herbal compounds can interact with antipsychotic medications, and the nurse needs to gather more information. Option 2 is incorrect because herbal compounds can have effects on the person. The nurse should not give blanket advice concerning herbal medications without consulting the physician. Option 4 is not a correct response since the nurse should not speak for another health professional.
A client admitted with delusions, hallucinations, and thought disorder has the admitting diagnosis schizophreniform disorder R/O organic pathology. Based on this information, the nurse can expect that the client will: 1. Undergo an MRI test 2. Have psychological testing 3. Have an immunologic assay performed 4. Participate in a dexamethasone suppression test
ANS: 1 The MRI will reveal structural changes in the brain that might be responsible for symptoms of psychosis (e.g., abscess, tumor). 2. Psychologic testing may be performed but will be less definitive in ruling out organic pathology. 3. Immunologic studies are not indicated. 4. The DST is related to depression.
Prior to discharge, the nurse plans to teach the client and family about relapse. Which items will the nurse include in the teaching? 1. Recognition of warning signs of relapse 2. Notify the nurse of warning signs present for more than one month 3. Lower medication dosage to manage emerging side effects 4. Use street drugs judiciously and only in small amounts
ANS: 1 The client and family must be aware of signs of impending relapse. These signs are usually similar to those that the client experienced prior to hospitalization and will be client-specific. 2. The nurse should be notified ASAP, rather than waiting two weeks. 3. Clients should never adjust medication dosage. 4. Street drug use often precipitates relapse since many street drugs are dopaminergic.
A 32-year-old client with an admitting diagnosis of catatonic schizophrenia has been mute and motionless for 2 days. The priority nursing diagnosis is: 1. Risk for deficient fluid volume 2. Impaired physical mobility 3. Impaired social interaction 4. Ineffective coping
ANS: 1 The highest priority for the client is maintenance of basic physiologic needs while the client is stuporous. Option 2: Mobility is of lesser importance than fluid volume. Options 3 and 4 are not physiologic needs.
The wife of a client diagnosed with paranoid schizophrenia asks, "I've been told that my husband's illness is probably related to imbalanced brain chemicals. Can you be more specific?" The response based on the dopamine hypothesis is: 1. "An increase in the brain chemical dopamine explains the presence of delusions and hallucinations." 2. "An increase in the brain chemical dopamine explains the presence of lack of motivation and disordered affect." 3. "Decreased amounts of the brain chemical dopamine explain the presence of delusions and hallucinations." 4. "Breakdown of dopamine produces LSD, which in large amounts produces psychosis."
ANS: 1 The statement in option 1 is true. The other statements are false.
A client tells the nurse, "I hear people whispering about me. When I'm in the day room and they do that, I want to punch them." The information the nurse should give to staff in report consists of which of the following? 1. "Treat this client matter-of-factly. Be direct; don't talk about him or others in his presence." 2. "Stay away from this client. The fewer interactions you have with him, the fewer misinterpretations there will be." 3. "Stay close to this client and use touch as you interact with him." 4. "To help him become less anxious with whispering, speak in a very soft voice when you are near him."
ANS: 1 This approach is important when providing care for a client who is misinterpreting reality and is suspicious of the motives of others. 2. This ostracizes the client and is nontherapeutic. 3. Clients often misinterpret touch as threatening. This might promote loss of control. 4. This direction would be nontherapeutic as it would increase client anxiety and promote loss of control.
A client with paranoid schizophrenia has said she feels like throwing a chair. The nurse in the dayroom hears this and wishes to encourage verbalization as a deescalation technique. Which response by the nurse would fulfill this plan?
ANS: 1 Using how, what, and when to gather information is a nonthreatening approach. It will promote client verbalization and explanation of events without causing the client to become defensive. 2. This response sounds threatening even though it may be meant to remind the client of limits. 3. Why questions are demanding and threatening to clients. 4. This sidesteps the problem. Clients who are becoming aggressive should have nonstimulating environments with as few people present as possible. Sending the client into group therapy flouts that principle.
In planning aftercare for a client with schizophrenia and whose insurance benefits have been exhausted, the nurse who is concerned about overcoming negative symptoms will make provisions for the client to have stimulation, structure, socialization, and support. Which option would best incorporate these factors? 1. Day hospitalization 2. Attending a psychosocial club 3. Living with his elderly mother 4. Spending free time in the mall
ANS: 2 A psychosocial club is organized to provide the 4 S's and is not costly to clients. 1. Day hospitalization would not be possible because of the lack of insurance benefits. 3. This solution might fall short of stimulation and support. 4. Spending time in the mall lacks structure, socialization, and support.
A severely depressed client who had been successfully treated 5 years earlier using clomipramine (Anafranil) was admitted to the adult psychiatric unit where clomipramine was again ordered. For which medication side effects should the client be monitored? 1. Polyuria and coarse hand tremors 2. Orthostatic hypotension and constipation 3. Excess salivation and drooling 4. Muscle rigidity and restlessness
ANS: 2 Alpha1 blockade produces orthostatic hypotension, and cholinergic blockade produces constipation. 1. Mild tremors and urinary retention may occur. 3. This may occur with SSRIs. 4. This may occur with antipsychotics.
A client with schizophrenia tells the nurse as they sit in the day room, "I hear voices telling me bad things." The most therapeutic response the nurse can make is: 1. "Tell me what the voices are saying." 2. "I understand you hear these so-called voices, but I hear only the people in the room talking." 3. "The voices are not real. They're only your imagination." 4. "Do you think the voices would go away if we went into your room to talk?"
ANS: 2 By voicing his or her own reality related to the voices, the nurse does not deny the client's experiences but helps the client distinguish actual voices from those resulting from internal stimulation. Option 1 validates the reality of the voices. Option 3 will cause the client to defend his perceptions and thereby reinforce the importance of the hallucination. Option 4 again validates the reality of the voices and is not a helpful action since the voices go where the client goes.
A 34-year-old male admitted with catatonic schizophrenia has been mute and motionless for several days while at home prior to admission. He still appears stuporous in the hospital. Which nursing intervention would be an initial priority? 1. Orienting the client to the unit 2. Assessing the client for physical problems 3. Establishing a nonthreatening relationship 4. Reinforcing reality with the client
ANS: 2 Clients who are mute and motionless and inattentive to environmental stimuli are at risk for a number of physical problems. Further, they are unable to communicate existing problems. The nurse must make thorough and astute assessments before creating plans to meet the client's needs. 1. A client who is stuporous may not be able to attend to information given about unit rules and protocols. 3. This is an important intervention but not the priority according to Maslow's hierarchy. 4. Because the client is mute, one can only suspect lack of reality orientation. While an appropriate intervention, it is not the priority according to Maslow's hierarchy.
25. A client with catatonic schizophrenia has been posturing, standing with his left arm upraised and his right foot off the floor. For the most part, he ignores attempts at nursing intervention but will occasionally walk, sit, or lie down for a few minutes. The client eats standing up if the nurse brings a tray to the room. The priority nursing order would be to: 1. Insist that client sit or lie down for 30 minutes hourly 2. Assess for lower extremity edema bid 3. Provide high-calorie drinks hourly 4. Take client to activities therapy once daily
ANS: 2 Clients who maintain one position for long periods of time should be assessed for dependent edema. In this case, the nurse would look for edema of the lower extremities and would be concerned about the pressure exerted by standing on one foot for long periods of time. 1. Insistence would probably be met with resistance by the client. 3. High-calorie drinks would be necessary if the client failed to eat at meals. 4. The client probably would not be able to cognitively process what is required to participate in activities.
A client who has been diagnosed as having paranoid schizophrenia is highly suspicious and delusional. He hears voices telling him terrorists are plotting to assassinate him. He refuses to eat, saying the food is poisoned. The nursing action that best addresses his needs is to: 1. Explain that others eat the food and are not harmed 2. Allow client to select food from vending machines 3. Assist client with personal hygiene and grooming 4. Not allow client to verbalize delusional thoughts
ANS: 2 Clients who think hospital food is being poisoned will sometimes eat wrapped foods that have not been opened, and occasionally, they may eat food brought from the outside by a trusted person. 1. Delusions are fixed, false beliefs that cannot be refuted by logic. The client will probably state that the others have been given the antidote to the poison. 3. No data exist to the effect that the client has inadequate hygiene and grooming. 4. Although it is wise to minimize the amount of discussion about delusions, refusing to allow the client to speak about the delusions will not foster a therapeutic alliance.
The nurse is administering haloperidol (Haldol) to a client experiencing delusions and hallucinations associated with schizophrenia. The nurse can expect symptom abatement as a result of the drug's action to: 1. Reduce the number of brain cells that crave dopamine 2. Block dopamine receptors, making dopamine less available 3. Enhance dopamine receptors, making more dopamine available 4. Cause increased cellular production of dopamine
ANS: 2 Excess dopamine is responsible for symptoms of psychosis such as delusions and hallucinations. Blocking dopamine receptors will result in reduction of primary symptoms. The other options do not reflect the action of typical antipsychotic medications.
Which of the following interventions should the nurse plan to use to reduce client focus on delusional thinking? 1. Confronting the delusion 2. Focusing on feelings suggested by the delusion 3. Refuting the delusion with logic 4. Exploring reasons the client has the delusion
ANS: 2 Focusing on feelings suggested by the delusion will help meet client needs and help the client stay reality-based. This technique fosters rapport and trust while discouraging the belief without challenging or refuting it.
A client, age 45, who has schizophrenia was admitted to the hospital 1 month after his last hospitalization. He demonstrates psychotic behaviors. He lives alone and has not taken the oral haloperidol (Haldol) that was prescribed. Which intervention would promote medication compliance? 1. Instructing the client to have friends monitor his medications 2. Begin administration of haloperidol (Haldol) decanoate 3. Writing instructions in detail for the client to follow 4. Changing haloperidol to an atypical antipsychotic
ANS: 2 Haloperidol decanoate is a depot medication, given IM every 2 to 4 weeks. 1. It is unknown whether the client has a support system. 3. The client probably received education, including written instructions prior to discharge. 4. This action would not necessarily improve compliance.
An acutely psychotic individual diagnosed with schizophreniform disorder at admission is immediately placed on daily doses of risperidone. A hospitalization of 8 days' duration has been authorized by the HMO. By what hospital day would the nurse expect to note that client was demonstrating beginning trust in the nurse and reduction in hallucinations and delusions? 1. Day of admission 2. Day 3 of hospitalization 3. Day 5 of hospitalization 4. Day 7 of hospitalization
ANS: 2 Having received antipsychotic medication for 3 days, it is conceivable that the florid symptoms of psychosis would be diminishing and the client would demonstrate beginning trust in the nurse. For the other options, one would expect greater degrees of symptom remission.
The mother of a client newly diagnosed with schizophrenia is a nurse. She unhappily tells the nurse on the unit, "I've tried to be a good mother, but my daughter still developed schizophrenia. When I was in school, we were taught that it was the mother's fault if a child became schizophrenic. I wish I knew what I did wrong." The response that would help the mother evaluate models explaining schizophrenia would be: 1. "I can see how you would be upset over this turn of events." 2. "New findings suggest this disorder is biologic in nature." 3. "Don't be so hard on yourself; your daughter needs you to be strong." 4. "It's difficult to see that double-bind communication produces stress for the child at the time it's occurring."
ANS: 2 Many individuals in the mental health field attribute the development of schizophrenia to multiple causes centering on biologic theories. Options 1, 3, and 4 do little to provide the mother with new information.
A client with schizophrenia is medication compliant and has well-controlled symptoms. He has, however, never been successful in holding a job because of poor social skills and lack of understanding of basic job skills. The nurse case manager should consider referring the client: 1. To a day hospital program 2. For psychosocial rehabilitation 3. For cognitive therapy 4. To assertiveness training
ANS: 2 Psychosocial rehabilitation helps clients readjust to community living by promoting development of necessary skills. Social skills training and job skills training programs are usually available. 1. The client does not need the more intensive services found in a day hospital. 3. Cognitive therapy will not offer the needed community living skills training. 4. Assertiveness training is only a small portion of the community living skills the client needs.
A 19-year-old client is admitted for the second time in 9 months and is acutely psychotic with a diagnosis of undifferentiated schizophrenia. The client sits alone rubbing her arms and smiling. She tells the nurse her thoughts cause earthquakes and that the world is burning. The nurse assesses the primary deficit associated with the client's condition as: 1. Altered mood states 2. Disturbed thinking 3. Social isolation 4. Poor impulse control
ANS: 2 The nurse interprets the client's statements that were not reality-based as indicating disturbed thought processes. Options 1 and 4: No data exist pointing to these conclusions. Option 3: Social isolation is not the primary client problem.
A client has been admitted with disorganized type schizophrenia. The nurse observes blunted affect and social isolation. The client occasionally curses or calls another client a "jerk" without provocation. The nurse asks the client how he is feeling, and he responds, "Everybody picks on me. They frobitz me." The best response for the nurse to make would be: 1. "That's really too bad." 2. "Who do you mean when you say 'everybody'?" 3. "What difference does frobitzing make?" 4. "Why do they frobitz?"
ANS: 2 This response will help clarify the client's thinking and change the focus from global to specific. Option 1 sympathizes and is a nonproductive response. Options 3 and 4 accept the client's neologism. Accepting the neologism supports the client's delusional thinking.
During a medication management class for nurses, the pharmacist discussing tricyclic antidepressants asked how these medications affect neurotransmitter activity. The nurse should respond: 1. "By decreasing available dopamine." 2. "By increasing availability of norepinephrine and serotonin." 3. "By making available increased amounts of monoamine oxidase." 4. "By increasing the effects of gamma-aminobutyric acid."
ANS: 2 Tricyclic antidepressants block neurotransmitter uptake, increasing the amounts of norepinephrine and serotonin available. 1. This is the action of typical antipsychotic medication. 3. This is not the action of tricyclics. 4. Benzodiazepines, not tricyclics, increase the effects of GABA.
An appropriate intervention for a client with an identified nursing diagnosis of Situational low self-esteem would be: 1. Encouraging verbalization of feelings in a safe environment 2. Attempting to determine triggers to hallucinations 3. Engaging client in activities designed to permit success 4. Providing large muscle activities to relieve stress
ANS: 3 All are useful interventions for a client with schizophrenia; however, engaging the client in specifically designed activities is the only option that addresses improving self-esteem.
An expected outcome for a client who hears voices telling him he is evil would be that by discharge, client will: 1. Verbalize the reason the voices say he is evil 2. Respond verbally to the voices 3. Identify events that increase anxiety and promote hallucinations 4. Integrate the voices into his personality structure in a positive manner
ANS: 3 An appropriate outcome for a client with hallucinations is recognition of events that precede the onset of hallucinations. Trigger events or situations usually cause increased feelings of anxiety. 1. This is not an event indicating progress. 2. This does not indicate improvement; it may make the client more unacceptable to others. 4. This is not desirable.
A client who received chlorpromazine (Thorazine) for 15 years to treat schizophrenia developed tardive dyskinesia as evidenced by tongue thrusting and chewing motions. The physician discontinued the chlorpromazine and prescribed Seroquel (quetiapine). As a result of this change, the nurse should carefully monitor for: 1. Development of pseudoparkinsonism 2. Development of dystonic reactions 3. Improvement in tardive dyskinesia 4. Worsening of anticholinergic symptoms
ANS: 3 Atypical antipsychotics have been noted to block oral dyskinesia and improve tardive dyskinesia as well as improve both positive and negative symptoms of schizophrenia. Options 1 and 2 are associated with typical antipsychotic medication. Option 4: Anticholinergic symptoms are not intense with use of atypical antipsychotic medication.
The nurse manager on the psychiatric unit was explaining to the new staff the differences between typical and atypical antipsychotics. She correctly stated that atypical antipsychotics: 1. Remain in the system longer 2. Act more quickly to reduce delusions 3. Produce fewer extrapyramidal effects 4. Are risk free for neuroleptic malignant syndrome (NMS)
ANS: 3 Atypical antipsychotics produce less D2 blockade; thus movement disorders are less of a problem. Options 1 and 2: No evidence suggests this. Option 4: The atypicals are not risk-free for NMS.
A 28-year-old female client was admitted 3 days ago after she ran nude through the streets shouting that she was the "Queen of Hearts." Since admission, the client remains delusional, shouts obscenities, and demonstrates loosely associated thoughts. Based on these data, the nurse should develop a nursing diagnosis of: 1. Risk for violence 2. Defensive coping 3. Disturbed thought processes 4. Impaired memory
ANS: 3 Delusions and loose associations suggest disturbed thought processes. 1. No data exist to support the diagnosis risk for violence. 2. This diagnosis is not supported by data in the scenario. 4. No data exist to support memory impairment.
A 28-year-old female client was admitted 3 days ago after she ran nude through the streets, shouting that she was the "Queen of Hearts." The client has remained delusional since admission. An initial expected outcome would be that the client will: 1. Allow the nurse to logically dispute the delusion 2. Distinguish external boundaries 3. Engage in reality-oriented conversation 4. Explain why she thinks she is the "Queen of Hearts"
ANS: 3 Delusions are not reality-oriented; thus an appropriate outcome would be that client will engage in reality-oriented conversation rather than discussing delusional beliefs. 1. Delusions are fixed, false beliefs. Clients rarely accept anyone using logic to dispute them. 2. Data are not present to suggest boundary disturbance. 4. Explaining the delusion is not progress; it suggests the client still holds to the belief.
During a treatment team meeting, the point is made that a client with schizophrenia has recovered from the acute psychosis but continues to demonstrate apathy, avolition, and blunted affect. The nurse who relates these symptoms to serotonin (5HT2) excess will suggest that the client receive: 1. Haloperidol (Haldol) 2. Chlorpromazine (Thorazine) 3. Olanzapine (Zyprexa) 4. Phenelzine (Nardil)
ANS: 3 Olanzapine is an atypical antipsychotic. Atypical antipsychotic medications are more effective than typical antipsychotics in blocking serotonin receptors and reducing the negative symptoms of schizophrenia. Options 1 and 2 are typical antipsychotic medications. Option 4 is an MAOI antidepressant.
A client experiences intrusive, insulting auditory hallucinations. Which independent behavioral technique can the nurse teach the client to employ when the voices are troublesome? 1. Take additional antipsychotic medication. 2. Lie down in bed and try to sleep. 3. Sing or whistle to compete with the voices. 4. Eat a large portion of chocolate.
ANS: 3 This action provides an alternative to listening to the voices and gives the client a sense of control. 1. The client should not adjust medication dose upward or downward independently. 2. Going to bed is limiting and not particularly effective, because the voices are uncontested in a quiet atmosphere. 4. Eating chocolate has no effect on hallucinations.
A client has been admitted with disorganized type schizophrenia. The nurse observes blunted affect and social isolation. He occasionally curses or calls another client a "jerk" without provocation. The nurse asks the client how he is feeling, and he responds, "Everybody picks on me. They frobitz me." The nurse would assess "frobitz" as: 1. Circumstantial speech 2. Loose associations 3. Evidence of delusional thinking 4. A neologism
ANS: 4 A newly coined word having meaning only for the client is called a neologism (meaning, new word). It is associated with autistic thinking. Options 1 and 2: Other than the use of the neologism, the client's speech does not show associative looseness or circumstantiality. Option 3: The use of a neologism is not delusional in and of itself, but it suggests delusional thinking may be present.
A 34-year-old client with residual schizophrenia frequently displays ambivalence. The community mental health nurse suggests that a realistic short-term outcome for this client problem is that client will: 1. Decide his or her own daily schedule 2. Refuse to attend activities 3. Choose which clinic staff member to work with 4. Choose between two outfits to wear each morning
ANS: 4 An early step would be to make choices about nonthreatening matters when presented with limited alternatives. 1. This involves many choices. 2. Negativity is one way ambivalence is manifested, so this would not indicate improvement. 3. This represents a choice of huge importance, rather than being a simple matter.
A community mental health nurse receives a new client for his caseload. The diagnosis of the client is residual schizophrenia. Documentation states that the client has a number of negative symptoms. Which symptom would the nurse expect to assess in the client? 1. Bizarre, somatic delusions 2. Disorganized speech pattern 3. Catatonic posturing 4. Emotional blunting
ANS: 4 Blunted affect is considered a negative symptom. The other symptoms would be classified as positive symptoms.
A mother discusses her concerns about genetic transmission of schizophrenia with the nurse saying, "My son is a fraternal twin. He has been diagnosed with schizophrenia. Will my other son develop schizophrenia, too?" The response that is both sensitive and shows understanding of the genetic component is: 1. "You poor woman! I wish I could tell you he will be free of the disorder." 2. "Studies show that 50% of twins develop schizophrenia when it is present in the other twin." 3. "No one can say what will happen, so we will hope for the best for you and your sons." 4. "In fraternal twins, the chance of the other twin developing the disorder is quite small."
ANS: 4 Option 4 is a true statement and sensitively stated, whereas options 2 and 3 are not factual. Option 1 demonstrates a sympathetic and therefore nontherapeutic response.
A client with undifferentiated schizophrenia is readmitted for an acute exacerbation of the disorder. The goal of hospitalization is symptom stabilization. The nurse has documented that, in addition to experiencing auditory hallucinations, the client seems uninterested in activities, has difficulty completing tasks, seems forgetful, and seems puzzled by information and directions given by staff. The nurse's plans for intervention will be effective if these behaviors are attributed to: 1. Social isolation 2. Deficient knowledge 3. Situational low self-esteem 4. Problems in cognitive functioning
ANS: 4 Schizophrenia may alter cognitive functioning, including memory, retention, attention, and the processing of incoming information. Altered cognition accounts for many of the symptoms mentioned in the scenario. Knowing that cognition is altered, the nurse can adjust plans to take the deficits into account. Options 1, 2, and 3 do not adequately explain the symptoms given in the scenario.
A client displays disorganized thinking, difficult-to-follow speech, and silly, inappropriate affect. The client isolates himself from other clients and staff, ignores unit activities, and often seems to be listening and responding to unseen stimuli. This client's behavior most closely conforms to the characteristic behavior of: 1. Residual schizophrenia 2. Schizoaffective disorder 3. Paranoid schizophrenia 4. Disorganized schizophrenia
ANS: 4 The presence of disorganization and inappropriate affect identifies this disorder as disorganized schizophrenia. 1. The symptoms are too florid to be residual schizophrenia. 2. Schizoaffective disorder presents with severe mood disorder along with symptoms of schizophrenia. 3. Paranoid schizophrenia is characterized by persecutory or grandiose delusions.
A client on an antipsychotic medication develops a high fever, unstable blood pressure, and muscle rigidity. Her next dose of medication is due. The nurse should: 1. Administer the medication and take the vital signs again 2. Give a lower dose of the medication and take the blood pressure 3. Prepare to give the prn anticholinergic, benztropine (Cogentin) 4. Hold the medication and call the client's doctor immediately
ANS: 4 These symptoms could be related to neuroleptic malignant syndrome (NMS), and the nurse should hold the medication and contact the doctor.
A client is admitted to the psychiatric unit with a diagnosis of major depression. The client is unable to concentrate, has no appetite, and is experiencing insomnia. Which should be included in this client's plan of care? A. A simple, structured daily schedule with limited choices of activities B. A daily schedule filled with activities to promote socialization C. A flexible schedule that allows the client opportunities for decision making D. A schedule that includes mandatory activities to decrease social isolation
ANS: A A client diagnosed with depression has difficulty concentrating and may be overwhelmed by activity overload or the expectation of independent decision making. A simple, structured daily schedule with limited choices of activities is more appropriate.
A nurse reviews the laboratory data of a client suspected of having major depressive disorder. Which laboratory value would potentially rule out this diagnosis? A. Thyroid-stimulating hormone (TSH) level of 6.2 U/mL B. Potassium (K+) level of 4.2 mEq/L C. Sodium (Na+) level of 140 mEq/L D. Calcium (Ca2+) level of 9.5 mg/dL
ANS: A According to the DSM-IV-TR, symptoms of major depressive disorder cannot be due to the direct physiological effects of a general medical condition (e.g., hypothyroidism). The diagnosis of major depressive disorder may be ruled out if the client's laboratory results indicate a high TSH level which results from a low thyroid function or hypothyroidism. In hypothyroidism, metabolic processes are slowed leading to depressive symptoms.
An isolative client was admitted 4 days ago with a diagnosis of major depressive disorder. Which nursing statement would best motivate this client to attend a therapeutic group being held in the milieu? A. "We'll go to the day room when you are ready for group." B. "I'll walk with you to the day room. Group is about to start." C. "It must be difficult for you to attend group when you feel so bad." D. "Let me tell you about the benefits of attending this group."
ANS: B A client diagnosed with major depressive disorder exhibits little to no motivation and must be firmly directed by staff to participate in therapy. It is difficult for a severely depressed client to make decisions, and this function must be temporarily assumed by the staff.
A client is diagnosed with major depressive disorder. Which nursing diagnosis should a nurse assign to this client to address a behavioral symptom of this disorder? A. Altered communication R/T feelings of worthlessness AEB anhedonia B. Social isolation R/T poor self-esteem AEB secluding self in room C. Altered thought processes R/T hopelessness AEB persecutory delusions D. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia
ANS: B A nursing diagnosis of social isolation R/T poor self-esteem AEB secluding self in room addresses a behavioral symptom of major depressive disorder. Other behavioral symptoms include psychomotor retardation, virtually nonexistent communication, maintaining a fetal position, and no personal hygiene and/or grooming.
A nurse is implementing a one-on-one suicide observation level with a client diagnosed with major depressive disorder. The client states, "I'm feeling a lot better so you can stop watching me. I have taken up too much of your time already." Which is the best nursing reply? A. "I really appreciate your concern but I have been ordered to continue to watch you." B. "Because we are concerned about your safety, we will continue to observe you." C. "I am glad you are feeling better. The treatment team will consider your request." D. "I will forward you request to your psychiatrist because it is his decision."
ANS: B Often suicidal clients resist personal monitoring which impedes the implementation of a suicide plan. A nurse should continually observe a client when risk for suicide is suspected.
A newly admitted client is diagnosed with major depressive disorder with suicidal ideations. Which would be the priority nursing intervention for this client? A. Teach about the effective of suicide on family dynamics. B. Carefully and unobtrusively observe based on assessed data, at varied intervals around the clock. C. Encourage the client to spend a portion of each day interacting within the milieu. D. Set realistic achievable goals to increase self esteem.
ANS: B The most effective way to interrupt a suicide attempt is to carefully, unobtrusively observe based on assessed data at varied intervals around the clock. If a nurse observes behavior that indicates self-harm, the nurse can intervene to stop the behavior and keep the client safe.
What is the rationale for a nurse to perform a full physical health assessment on a client admitted with a diagnosis of major depressive disorder? A. The attention during the assessment is beneficial in decreasing social isolation. B. Depression can generate somatic symptoms that can mask actual physical disorders. C. Physical health complications are likely to arise from antidepressant therapy. D. Depressed clients avoid addressing physical health and ignore medical problems.
ANS: B The nurse should determine that a client with a diagnosis of major depressive disorder needs a full physical health assessment because depression can generate somatic symptoms that can mask actual physical disorders. Somatization is the process by which psychological needs are expressed in the form of physical symptoms.
A depressed client reports to a nurse a history of divorce, job loss, family estrangement, and cocaine abuse. Which theoretical principle best explains the etiology of this client's depressive symptoms? A. According to psychoanalytic theory, depression is a result of anger turned inward. B. According to object-loss theory, depression is a result of abandonment. C. According to learning theory, depression is a result of repeated failures. D. According to cognitive theory, depression is a result of negative perceptions.
ANS: C The nurse should assess that this client's depressive symptoms may have resulted from repeated failures. This assessment was based on the principles of learning theory. Learning theory describes a model of "learned helplessness" in which multiple life failures cause the client to abandon future attempts to succeed.
The nurse is providing counseling to clients diagnosed with major depressive disorder. The nurse chooses to assess and attempt to modify the negative thought patterns of these clients. The nurse is functioning under which theoretical framework? A. Psychoanalytic theory B. Interpersonal theory C. Cognitive theory D. Behavioral theory
ANS: C When a nurse assesses and attempts to modify negative thought patterns related to depressive symptoms, the nurse is using a cognitive theory framework.
A nurse is planning care for a child who is experiencing depression. Which medication is approved by the U.S. Food and Drug Administration (FDA) for the treatment of depression in children and adolescents? A. Paroxetine (Paxil) B. Sertraline (Zoloft) C. Citalopram (Celexa) D. Fluoxetine (Prozac)
ANS: D Fluoxetine (Prozac) is FDA approved for the treatment of depression in children and adolescents. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used in the treatment of depression. All antidepressants carry an FDA warning for increased risk of suicide in children and adolescents.
Which client statement expresses a typical underlying feeling of clients diagnosed with major depressive disorder? A. "It's just a matter of time and I will be well." B. "If I ignore these feelings, they will go away." C. "I can fight these feelings and overcome this disorder." D. "I deserve to feel this way."
ANS: D Hopelessness and helplessness are typical symptoms of clients diagnosed with major depressive disorder. Depressive symptoms are often described as anger turned inward.
A client diagnosed with seasonal affective disorder (SAD) states, "I've been feeling 'down' for 3 months. Will I ever feel like myself again?" Which reply by the nurse will best assess this client's symptoms. A. "Have you been diagnosed with any physical disorder within the last 3 months?" B. "Have you experienced any traumatic events that triggered this mood change?" C. "People who have seasonal mood changes often feel better when spring comes." D. "Help me understand what you mean when you say, 'feeling down'?"
ANS: D The nurse is using a clarifying statement in order to gather more details related to this client's mood. The diagnosis of SAD is not associated with a traumatic event.
A nurse assesses a client suspected of having major depressive disorder. Which client symptom would eliminate this diagnosis? A. The client is disheveled and malodorous. B. The client refuses to interact with others. C. The client is unable to feel any pleasure. D. The client has maxed-out charge cards and exhibits promiscuous behaviors.
ANS: D The nurse should assess that a client who has maxed-out credit cards and exhibits promiscuous behavior would be exhibiting manic symptoms. According to the DSM-IV-TR, these symptoms would rule out the diagnosis of major depressive disorder.
A client is diagnosed with dysthymic disorder. Which should a nurse classify as an affective symptom of this disorder? A. Social isolation with a focus on self B. Low energy level C. Difficulty concentrating D. Gloomy and pessimistic outlook on life
ANS: D The nurse should classify a gloomy and pessimistic outlook on life as an affective symptom of dysthymic disorder. Symptoms of depression can be described as alterations in four areas of human functions: affective, behavioral, cognitive, and physiological.
The nurse is assessing a young client admitted to the psychiatric unit for acute depression related to a recent divorce. Which statement is most indicative of a client suffering from depression? A. "I'm not very pretty or likeable." B. "I've lost 20 pounds in the past month." C. "I like to keep things to myself." D. "I think everyone is out to get me."
Correct Answer: A Rationale: Feelings of hopelessness (A) are characteristic of one who is depressed. Although (B) might be indicative of depression, further assessment would be required to rule out an organic cause before attributing the statement to depression. (C and D) are indicative of a paranoid personality.
A client who recently retired is admitted to the psychiatric inpatient unit with a diagnosis of major depression. The initial nursing care plan includes the goal, "Assist client to express feelings of guilt." What is true about the goal statement referring to the client's depression? A. Implementation of the goal should be deferred until further data can be gathered. B. The depression will dissipate once the client becomes accustomed to retirement. C. Depressed clients may be unaware of guilt feelings and should be encouraged to increase self-awareness. D. Nursing goals should be approved by the treatment team before they are initiated.
Correct Answer: C Rationale: Depression is associated with feelings of guilt, and clients are often not aware of these feelings (C). Awareness is the first step in dealing with guilt (or any other feeling), so the nurse's efforts should be directed toward increasing the client's awareness of feelings. Although a goal may be changed based on an evaluation of interventions to meet the goal, a goal should never be ignored (A). (B) dismisses the client's symptoms as age-related. Setting goals for the nursing care plan is a function of the nurse (D), although the nurse can collaborate with the treatment team.
