Psychiatric Nursing - Psychotic Disorders

The plan of care for an outpatient client with schizophrenia includes risperidone therapy. The nurse prepares to administer this drug based on the understanding of which factor? The positive symptoms of schizophrenia are usually more prominent than the negative symptoms. Agranulocytosis is less of a risk with risperidone therapy than with clozapine. Typical antipsychotics help with negative symptoms, but not as well as risperidone does. Risperidone is less expensive than traditional antipsychotics.

Agranulocytosis is less of a risk with risperidone therapy than with clozapine.

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. Preforming a suicide assessment on a client recently admitted with depression. Educating a client on the newly prescribed escitalopram and zolpidem. Assessing a client who is withdrawing from alcohol and methamphetamine.

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

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 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. 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 show no self-harm or harm to staff.

A client on an inpatient psychiatric unit has had several episodes of auditory hallucinations. Currently, the client is not having hallucinations and is interacting appropriately. Which nursing assessment is a priority? client anxiety levels throughout the day compliance with medications over the past 6 months characteristics and tone of the last hallucination deficits in cognitive function

client anxiety levels throughout the day

The nurse is planning the care of a client with schizophrenia. The nurse understands that the client will need the most extensive laboratory monitoring regiment if which medication is prescribed? clozapine haloperidol olanzapine risperidone

clozapine

The nurse is monitoring a client who appears to be hallucinating. The client displays paranoid speech content, seems agitated, and gestures at a figure on the television. Which nursing interventions are appropriate? Select all that apply. In a firm voice, instruct the client to stop the behavior. Reinforce that the client is not in any danger. Acknowledge the presence of the hallucinations. Instruct other team members to ignore the client's behavior. Delegate client assessment to a licensed practical/vocational nurse Use a calm voice and simple commands.

Reinforce that the client is not in any danger. Use a calm voice and simple commands. Acknowledge the presence of the hallucinations.

A nurse is assigned to a client with catatonic schizophrenia. Which intervention should the nurse include in this client's care plan? meeting all of the client's physical needs giving the client an opportunity to express concerns administering lithium carbonate as ordered providing a quiet environment in which the client can be alone

meeting all of the client's physical needs

A client is admitted to the psychiatric unit accompanied by her husband. She brings six suitcases and three shopping bags. She orders the nurse to carry her bags. Her husband states she has been purchasing items that they cannot afford and has not slept for 4 nights. Which additional information would be a priority for the nurse to seek from the client's husband? the client's fluid and food intake their current financial status the client's usual sleeping pattern whether or not the client becomes agitated easily

the client's fluid and food intake

A new nurse is leading a family education group for those who have relatives with paranoid schizophrenia. Which statement by the new nurse indicates the need for further teaching about symptom management? "When the clients get overwhelmed, it's best if they spend some time in their room." "The more we push the clients to spend time with friends, the more their voices decrease." "Until we get the clients up and going, they seem to have no motivation to do anything." "We still have to remind the clients that we do not hear the voices they do."

"The more we push the clients to spend time with friends, the more their voices decrease."

A client with schizophrenia states "I can't stay here. I have to get away." The nurse observes that the client is very agitated. What should be the nurse's first action? Approach the client in a calm, nonthreatening manner. Allow the client to express feelings. Ask the client to take lorazepam 1 mg orally. Call for help from the other staff.

Approach the client in a calm, nonthreatening manner.

A client experiencing paranoid thought distortions states, "The voices are telling me the others are aliens trying to steal my brain." How should the nurse therapeutically approach this client? Use logical and persistent communication with each contact. Encourage the ventilation of anger and frustration. State other voices are not heard, but do not argue. Confront the client with reality, and use positive reinforcement.

State other voices are not heard, but do not argue.

A client with a tentative diagnosis of psychosis is admitted to the psychiatric unit. A physician orders the phenothiazine thioridazine 50 mg by mouth three times per day. Phenothiazines differ from central nervous system (CNS) depressants in their sedative effects by producing: deeper sleep than CNS depressants. greater sedation than CNS depressants. a calming effect from which the client is easily aroused. more prolonged sedative effects, making the client more difficult to arouse.

a calming effect from which the client is easily aroused.

A client received haloperidol 12 hours previously. The client develops an oculogyric crisis and tongue protrusion. Which is a nursing priority intervention? administering diphenhydramine as ordered administering midazolam as ordered administering chlorpromazine as ordered administering diazepam as ordered

administering diphenhydramine as ordered

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? fears of abandonment and attention seeking enjoyment of bothering the staff boredom suggesting the need for something to do lack of desire for involvement in milieu activities

fears of abandonment and attention seeking

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: sit in a quiet, dark room and concentrate on the voices. listen to a personal stereo through headphones and sing along with the music. call a friend and discuss the voices and the client's feelings about them. engage in strenuous exercise.

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

A client with schizoaffective disorder is brought to the hospital by a family member. The family member states that the client is having an increase in auditory hallucinations and is becoming significantly more withdrawn. The nurse reviewing the admission blood work expects which blood level to be subtherapeutic? phenobarbital chlordiazepoxide lithium carbonate imipramine

lithium carbonate

A client's medication order reads, "Thioridazine 200 mg P.O. q.i.d. and 100 mg P.O. PRN" A nurse should: administer the medication as ordered. question the physician about the order. administer the order for 200 mg P.O. q.i.d. but not for 100 mg P.O. PRN. administer the medication as ordered but observe the client closely for adverse effects.

question the physician about the order.

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. leaving the room but telling the client that the nurse will return soon telling the client that there's no danger and that everything's fine telling the client that the alarm is just a drill and not to be afraid staying with the client until the nurse receives further instructions continuing to speak to the client in a reassuring tone

staying with the client until the nurse receives further instructions continuing to speak to the client in a reassuring tone

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 high for the client. too low for the client. typical when initiating therapy. typical when initiating therapy but it should be tapered down in 1 week.

typical when initiating therapy.

At an outpatient visit 3 months after discharge from the hospital, a client says he has stopped his olanzapine even though it controls his symptoms of schizophrenia better than other medications. "I've gained 20 lb (9.1 kg) already. I can't stand it anymore." Which response by the nurse is most appropriate? "I don't think you look fat; why do you think so?" "I can help you with a diet and exercise plan to keep your weight down." "You can be switched to another medicine." "Your weight gain will level off if you stay on the medication 3 more months."

"I can help you with a diet and exercise plan to keep your weight down."

A client on a psychiatric care unit has muscle spasms in the neck and stiffness in other muscles, and the eyes are rolling upward. The client had two PRN doses of haloperidol in the last 6 hours. Of the drugs that have been prescribed for the client as needed (see chart), which drug should the nurse administer? lorazepam amantadine diphenhydramine benztropine

benztropine

A client with schizophrenia becomes angry and tells a nurse to leave. The nurse should: agree to leave but explain the nurse will return soon. ask if it's OK to sit quietly with the client. ask why the client wants the nurse to leave. provide assurance that the nurse won't let anything happen to the client.

agree to leave but explain the nurse will return soon.

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: suggestibility. negativity. waxy flexibility. retardation.

waxy flexibility.

A 20-year-old client with paranoid schizophrenia is in the 4th day of hospitalization. The client's parents visit and state to the nurse, "What did we do wrong? What caused this awful thing to happen?" Which explanation by the nurse is most accurate and therapeutic? "We really do not know. There are many theories about schizophrenia." "Let's talk about your family background. Schizophrenia is often genetic." "You did not cause schizophrenia by doing something wrong. Schizophrenia is a brain disease." "Schizophrenia often appears for the first time in early adulthood when people with a predisposition experiment with drugs and alcohol."

"You did not cause schizophrenia by doing something wrong. Schizophrenia is a brain disease."

A nurse is working with a schizophrenic client who suddenly begins experiencing auditory hallucinations. Which interactions are appropriate at this time? Select all that apply. Ask the client, "What are you experiencing right now?" Encourage the client to relate the history of the hallucinations. Tell the client, "I'd like to spend time with you to discuss your hallucinations. Is that okay with you?" Ask the client if they have recently taken any drugs or alcohol. State, "Do you understand the side effects of your medication?" Notify the healthcare provider of hallucinations.

Ask the client, "What are you experiencing right now?" Tell the client, "I'd like to spend time with you to discuss your hallucinations. Is that okay with you?" Encourage the client to relate the history of the hallucinations. Ask the client if they have recently taken any drugs or alcohol.

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? Remind the client that hearing voices is a symptom of her illness that she can cope with. Check with the client's employer about her work performance. Obtain information about the client's medication compliance. Arrange for the client to be admitted to a psychiatric hospital for a short stay.

Obtain information about the client's medication compliance.

A nurse assessing a client with catatonia notes a lack of responsiveness and ridged posturing. What is the best nursing intervention? administer 2 mg lorazepam intramuscular injection (IM) assist the client to a more comfortable position infuse .9 normal saline (NS) 100 mL/hr assess the client's blood glucose level

administer 2 mg lorazepam intramuscular injection (IM)

When caring for a client receiving haloperidol, the nurse should assess for which problem? orthostasis extrapyramidal symptoms hypersalivation oversedation

extrapyramidal symptoms