Psychotic Disorders

The nurse observes that a client on a psychiatric unit is looking around the room with eyes darting to a chair in the corner. The client grimaces and then states, "Bastard," under their breath. Which nursing action is most appropriate? Ignore the client because they appear to be hallucinating. Approach the client to interrupt the hallucinations. Suggest the client spend some time in their room. Remind the client that vulgar language is not appropriate in the hospital.

Approach the client to interrupt the hallucinations.

The guardian of a client diagnosed with schizophrenia indicates to the nurse a concern that the client is at risk for suicide. Which question to the client would the nurse utilize to determine the seriousness of the suicidal idealization? "Do you have a gun at home?" "Are you taking your psychiatric medications?" "Do you have access to poisonous chemicals at home?" "Are you planning on hurting yourself?"

"Are you planning on hurting yourself?"

Which response demonstrates that the parents of a child with newly diagnosed schizophrenia understand their child's diagnosis? "We'll watch our child take the pills and call the physician if the child doesn't swallow them." "As long as we're understanding and supportive, our child will eventually be fine." "The illness is a result of drug abuse during early adolescence." "Our child's grandparent is an alcoholic. Being around the grandparent caused our child to have this problem."

"We'll watch our child take the pills and call the physician if the child doesn't swallow them."

A client admitted with a diagnosis of schizoaffective disorder, manic phase, who is currently taking fluoxetine, valproic acid, and olanzapine as prescribed, has had an increase in manic symptoms in the past week. The health care provider prescribes a valproic acid blood level to be drawn at once. What does the nurse understand is the rationale for this prescription? All clients taking valproic acid need periodic valproic acid levels drawn. Fluoxetine can decrease the effectiveness of the valproic acid. A decrease in the level of valproic acid could explain the increase in manic symptoms. The valproic acid level is needed before a short course of lorazepam for agitation can be prescribed.

A decrease in the level of valproic acid could explain the increase in manic symptoms.

Teaching for women of childbearing years who are receiving antipsychotic medications includes which statement? This medication may result in heightened libido. Incidence of dysmenorrhea may increase while taking this drug. Continue previous contraceptive use even if you're experiencing amenorrhea. Amenorrhea is irreversible.

Continue previous contraceptive use even if you're experiencing amenorrhea.

While planning the care for a client with paranoid delusions, which will be the nurse's initial goal for the client? Be free of delusions. Participate in unit activities. Meet self-care needs. Establish trust with staff.

Establish trust with staff.

A nurse is teaching a client about the prescribed drugs, chlorpromazine and benztropine. What evaluation would indicate a therapeutic response to these drugs? The client displays akathisia while sitting. The client is experiencing less psychosis and a decrease in extrapyramidal symptoms. The client does not report nausea and vomiting. The client expresses a decrease in anxiety.

The client is experiencing less psychosis and a decrease in extrapyramidal symptoms.

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.

An outpatient client with schizophrenia has been withdrawn from friends and family for 3 weeks. What is the most appropriate long-term goal for the client? calling the client's parent once a day attending day therapy three times a week allowing two friends to visit every day remaining out of bed for 10 hours a day

attending day therapy three times a week

The nurse is facilitating a group of clients with schizophrenia when one client says, "I like to drive my car, bar, tar, far." This client is exhibiting: clang association. echolalia. echopraxia. neologisms

clang association.

A client diagnosed with paranoid personality disorder is hospitalized for physically threatening their spouse because they suspect the spouse is having an affair with a coworker. What approach should the nurse employ with this client? authoritarian parental matter-of-fact controlling

matter-of-fact

A client is admitted with a diagnosis of schizotypal personality disorder. Which signs would this client exhibit during social situations? aggressive behavior paranoid thoughts emotional affect independence needs

paranoid thoughts

The client with histrionic personality disorder is melodramatic and responds to others and situations in an exaggerated manner. The nurse should recommend which activity for this client? party planning music group cooking class role-playing

role-playing

A client has been receiving chlorpromazine to treat psychosis. Which findings should alert the nurse that the client is experiencing pseudoparkinsonism? restlessness, difficulty sitting still, and pacing involuntary rolling of the eyes tremors, shuffling gait, and masklike face extremity and neck spasms, facial grimacing, and jerky movements

tremors, shuffling gait, and masklike face

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 25-year-old client diagnosed with schizophrenia states, "I stopped my medications a week ago. I was just tired of not being able to drink with my friends. Besides, I feel fine without them." Which response by the nurse is most appropriate? "It's important for you to go back on your medicines." "I hear how difficult it must be to live with the changes caused by your illness." "You'll have to talk to your health care provider (HCP) about stopping your medications." "Your buddies will understand that you can't drink anymore."

"I hear how difficult it must be to live with the changes caused by your illness."

A client with acute psychosis has been taking haloperidol for 3 days. When evaluating the client's response to the medication, the nurse understands that which comment reflects the greatest improvement? "I know these voices aren't real, but I'm still scared of them." "I'm feeling so restless, and I can't sit still." "Boy, do I need a shower. I think it's been days since I've had one." "I'm ready to talk about my discharge medications."

"I know these voices aren't real, but I'm still scared of them."

A client comes to the mental health clinic 2 days after being discharged from the hospital. The client was given a 1-week supply of clozapine. Which client statement indicates an accurate understanding of the nurse's teaching about this medication? "I need to call my health care provider in 2 weeks for a checkup." "I need to keep my appointment here at the clinic this week for a blood test." "I can drink alcohol with this medication." "I can take over-the-counter sleeping medication if I have trouble sleeping."

"I need to keep my appointment here at the clinic this week for a blood test."

After the nurse has taught a client who is being discharged on lithium about the drug, which client statement would indicate that the teaching has been successful? "I need to restrict eating any foods that contain salt." "If I forget a dose, I can double the dose the next time I take it." "I'll call my health care provider right away for any vomiting or muscle weakness." "I should increase my fluid intake to five to six 8-oz glasses (1200 to 1420 ml) of water each day."

"I'll call my health care provider right away for any vomiting or muscle weakness."

A client with bipolar disorder, manic phase, begins to swear at the nurse when reminded to limit telephone calls to 10 minutes. Which response should the nurse make? "You need to act like an adult." "You know better than to use that language." "Others can hear you." "Stop! Swearing is not appropriate behavior."

"Stop! Swearing is not appropriate behavior."

The parents of a 20-year-old client admitted 4 days ago with a diagnosis of paranoid schizophrenia are attending a family psychoeducation group in the hospital. Which statement indicates that the parents understand their child's illness and management? "I know that I'll have to do everything for my child when they come home." "Tasks as simple as getting out of bed and showering in the morning may be difficult." "I know that visits from friends at home should be discouraged for a while." "My child won't experience a relapse as long as they take their prescribed medication."

"Tasks as simple as getting out of bed and showering in the morning may be difficult."

The mother of a client with schizophrenia calls the visiting nurse in the outpatient clinic to report that their child has not answered the phone in 10 days. "They were doing so well for months. I don't know what's wrong. I'm worried." Which response by the nurse is most appropriate? "Maybe they're just mad at you. Did you have an argument?" "They may have stopped taking their medications. I'll check on them." "Don't worry about this. It happens sometimes." "Go over to their apartment and see what's going on."

"They may have stopped taking their medications. I'll check on them."

A client reports that people in blue clothes keep looking in their window and talking about them. Which response by the nurse is most appropriate? "Those people are groundskeepers. They are talking about their work, not you." "Don't take things so personally. Not everyone who is talking is talking about you." "Let's not pay attention to them. Let's play cards instead." "I'll close the drapes so you can't see them."

"Those people are groundskeepers. They are talking about their work, not you."

During the initial interview, a client with schizophrenia suddenly turns to an empty chair and whispers, "Now just leave. I told you to stay home. There isn't enough work here for both of us!" What is the nurse's best initial response? "When people are under stress, they may see things or hear things that others don't. Is that what just happened?" "I'm having a difficult time hearing you. Please look at me when you talk." "There is no one else in the room. What are you doing?" "Who are you talking to? Are you hallucinating?"

"When people are under stress, they may see things or hear things that others don't. Is that what just happened?"

Which concept is most important for a nurse to communicate to a client preparing to sign an informed consent for electroconvulsive therapy (ECT)? "You'll be offered a strong sedative before the procedure." "This therapy will provide excellent symptom relief." "You may experience a complete loss of memory after the treatment." "You may experience a time of confusion after the treatment."

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

A client is receiving haloperidol to reduce psychotic symptoms. As the client watches television with others, the nurse notes that the client is restless, constantly moving and changing position. When the nurse asks what is wrong, the client states feeling jittery. How should the nurse manage this situation? Ask the client to sit still or leave the room because the client is distracting the other clients. Assess the client's cardiac and respiratory system. Administer an as-needed dose of a prescribed beta-adrenergic blocker. Administer an as-needed dose of haloperidol.

Administer an as-needed dose of a prescribed beta-adrenergic blocker.

A client is admitted to the psychiatric emergency department with difficulty sleeping, poor judgment, and incoherent speech. The client reports being a special messenger from the Messiah who needs to be "sacrificed to save the world." Which action should the nurse take first? Administer an oral antipsychotic. Ask a family member to stay with the client. Institute suicide precautions. Encourage the client to describe the suicide plan.

Institute suicide precautions.

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. Acknowledge the presence of the hallucinations. Use a calm voice and simple commands.

When assessing a hospitalized client diagnosed with major depression and borderline personality disorder, the nurse should ask the client about which of the following first? Access to pills and weapons. Suicidal plans. Suicidal thoughts. Seriousness of the client's intent to die.

Suicidal thoughts.

A nurse caring for a client diagnosed with schizophrenia should perform which intervention when the client becomes suspicious and refuses to take their medication? Tell the client they must take the medication now, Attempt to coax the client into taking the medication by calling them "Honey." Wait for a short time and then attempt to administer the medication Document that the client is noncompliant

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

A client who was prescribed clozapine 2 months ago arrives in the clinic and informs the nurse that the they have been feeling extremely fatigued and feverish and has a sore throat. The nurse observes that the client has two small ulcerations of the oropharynx. Which does the nurse suspect may be occurring with this client? thiamine deficiency tardive dyskinesia agranulocytosis dystonic reaction

agranulocytosis

During a home visit for a client diagnosed with paranoid schizophrenia and discharged 1 week ago, the client's parent tearfully states, "I can hardly sleep because I'm so worried about my child. I'm afraid to leave them alone in the house. What if something happens while I'm gone?" Which caregiver problem would be the most inclusive one for the nurse to incorporate into the client's plan of care? caregiver role strain anxiety fear disturbed sleep pattern

caregiver role strain

A client with chronic schizophrenia receives 20 mg of fluphenazine decanoate by I.M. injection. Three days later, muscle contractions that contort the client's neck. This client is exhibiting which extrapyramidal reaction? dystonia akinesia akathisia tardive dyskinesia

dystonia

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

extrapyramidal symptoms

A client experiencing a schizophrenic episode is hospitalized. The client is attempting to hit and bite the staff. When the nurse phones the primary care provider for orders to help calm the client, the nurse anticipates what medication is likely to be ordered? chlorpromazine haloperidol lithium carbonate amitriptyline hydrochloride

haloperidol

A client diagnosed with borderline personality disorder has self-inflicted cuts on the arms. The nurse is assessing the client's risk for suicide. What should the nurse ask the client first? about medications the client has taken recently if the client is taking antidepressants if the client has a suicide plan why the client self-inflicted the cuts

if the client has a suicide plan

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

Which group of characteristics should a nurse expect to see in the client with schizophrenia? loose associations, grandiose delusions, and auditory hallucinations periods of hyperactivity and irritability alternating with depression delusions of jealousy and persecution, paranoia, and mistrust sadness, apathy, feelings of worthlessness, anorexia, and weight loss

loose associations, grandiose delusions, and auditory hallucinations

A client's nursing care plan includes the following prescription: "Assess for auditory hallucinations." What behavior would suggest to the nurse the client may be experiencing auditory hallucinations? inflated sense of power, knowledge, or identity elevated mood, hyperactivity, distractibility poor eye contact, tilted head, mumbling to self distrust, fear, suspicion

poor eye contact, tilted head, mumbling to self

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 client with schizophrenia tells the nurse, "My intestines are rotted from the worms chewing on them." This statement indicates a: delusion of persecution. delusion of grandeur. somatic delusion. jealous delusion.

somatic delusion.

After working multiple shifts in the psychiatric intensive care unit, a nurse is becoming more distant and, at times, even irritable. The best action for the nurse to take would be to: request vacation time in order to achieve emotional restoration. talk with the charge nurse and seek support from peers on the unit. ask the charge nurse if another, less-demanding assignment is available. continue to work and recognize that these feelings are normal.

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

When discharging a client after treatment for a dystonic reaction, an emergency department nurse must ensure that the client understands: results of treatment are rapid and dramatic but may not last. although uncomfortable, this reaction isn't serious. the client shouldn't buy drugs on the street. the client must take benztropine as ordered to prevent a return of symptoms.

the client must take benztropine as ordered to prevent a return of symptoms.

What should be charted by the nurse when the client has an involuntary commitment or formal admission status? Nothing should be charted. The forms are in the chart; there is no need to duplicate. The client's receipt of information about status and rights should be charted. The client's willingness to cooperate with seclusion should be charted. The name of the physician officially signing the certificates should be charted.

The client's receipt of information about status and rights should be charted.

A client whose symptoms of schizophrenia are under control with olanzapine, and who is functioning at home and in their part-time employment, states that they are very concerned about gaining 20 lb (9.1 kg) since starting the medication 6 months ago. What action should the nurse take? Suggest that the client talk with their health care provider about changing to another antipsychotic. Advise the client to decrease their dosage by one-half. Tell the client not to worry because they should stop gaining weight. Discuss nutrition, daily diet, and exercise with the client.

Discuss nutrition, daily diet, and exercise with the client.

A nurse is caring for a client who recently starting taking haloperidol. Which client assessment would be a priority for nurse follow up? Elevated liver function tests Neck stiffness with head tilt Frequent day naps Dry mouth with nausea

Neck stiffness with head tilt

The nurse is working in a community mental health clinic. A client who is diagnosed with schizophrenia is taking clozapine and reports of a sore throat. What is the most appropriate action for the nurse to take? Suggest that the client drink warm beverages and rest. Have the client decrease the daily amount of clozapine by half. Obtain an order for the client to have a white blood cell count drawn. Encourage the use of saline mouth rinses until the sore throat is gone.

Obtain an order for the client to have a white blood cell count drawn.

A nurse is caring for a client with schizophrenia. Which outcome requires revising the client's care plan? The client spends more time alone. The client doesn't engage in delusional thinking. The client doesn't harm self or others. The client demonstrates the ability to meet self-care needs.

The client spends more time alone.

A nurse is preparing a delusional client for a computed tomography scan of the brain to rule out an organic etiology. On the way to the radiology department, the client looks around anxiously and tells the nurse, "The Interpol is coming to kill me." What is the nurse's best response? "The Interpol isn't here." "Your illness is causing you to hear voices." "It sounds like you're frightened." "No one can hurt you here."

"It sounds like you're frightened."

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 nurse is caring for a client with schizoaffective disorder. The client is currently experiencing auditory hallucinations. Which nursing actions would take first priority for this client? encouraging the client to engage in one-on-one therapeutic conversations discussing with the client how to prevent relapse engaging the client in reality-based conversations acknowledging the client's strengths and accomplishments

engaging the client in reality-based conversations

A client with schizophrenia comes to the outpatient mental health clinic 5 days after being discharged from the hospital. The client was given a 1-week supply of clozapine. The client tells the nurse that they have too much saliva and frequently need to spit. The nurse interprets the client's statement as being consistent with which factor? delusion, requiring further assessment unusual reaction to clozapine expected adverse effect of clozapine unresolved symptom of schizophrenia

expected adverse effect of clozapine

A client with schizophrenia and delusions tells a nurse, "There is a man wearing a red coat who's out to get me." The client exhibits increasing anxiety when focusing on the delusion. Which response by the nurse is appropriate? "This subject seems to be troubling you. Let's walk to the activity room." "Describe the man who's out to get you. What does he look like?" "There is no reason to be afraid of that man. This hospital is very secure." "There is no need to be concerned about a man who isn't even real."

"This subject seems to be troubling you. Let's walk to the activity room."

A client admitted in an acute psychotic state hears terrible voices in their head and thinks a neighbor is mad at them. What is the nurse's best response? "What has your neighbor been doing that bothers you?" "How long have you been hearing these terrible voices?" "We won't let your neighbor visit, so you'll be safe." "What exactly are these terrible voices saying to you?"

"What exactly are these terrible voices saying to you?"

A client is in the withdrawn phase of catatonia due to schizophrenia. This is the client's first admission to an early psychosis program at an urban hospital. At present, the client is completely stuporous. What is the priority while giving care to the client during this phase of symptoms? Explain all physical care activities in simple, explicit terms as though expecting a response. Maintain a quiet atmosphere, speaking as little as possible to the client. Provide as much sensory stimulation as possible using conversation, radio, and television. Ask the client to do exactly the opposite of what is desired.

Explain all physical care activities in simple, explicit terms as though expecting a response.

A client with schizophrenia states, "I hear the voice of King Tut." Which response by the nurse is therapeutic? "I don't hear the voice, but I know you hear what sounds like a voice." "You shouldn't focus on that voice; it is not real." "Does the voice sound like someone you know?" "King Tut has been dead for years, so that can't be his voice."

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

The parent of a young adult client diagnosed with schizophrenia is asking questions about their child's antipsychotic medication, ziprasidone. Which statement by the parent reflects a need for further teaching? "If they experience restlessness or muscle stiffness, they should tell their health care provider (HCP)." "I should give them benztropine to help prevent constipation from the ziprasidone." "If they become dizzy, I'll make sure they don't drive." "The ziprasidone should help them be more motivated and less withdrawn."

"I should give them benztropine to help prevent constipation from the ziprasidone."

A client is admitted to the psychiatric unit with acute onset of schizophrenia. The physician orders the phenothiazine chlorpromazine, 100 mg by mouth four times per day. Before administering the drug, a nurse reviews the client's medication history. Concomitant use of which drug is likely to increase the risk of extrapyramidal effects? guanethidine droperidol lithium carbonate alcohol

droperidol

A client begins clozapine therapy after several other antipsychotic agents fail to relieve psychotic symptoms. The nurse instructs the client to return for weekly white blood cell (WBC) counts to assess for which adverse reaction? hepatitis infection granulocytopenia systemic dermatitis

granulocytopenia

After several months of taking olanzapine, the client reports that he is no longer hearing voices of any kind. Which statement would confirm that the client is developing insight into his illness? "That olanzapine is the best medicine I have ever had." "I didn't realize how sick I could get from a chemical brain imbalance." "My mom is proud of me for staying on my medicines." "I think I may be able to get a little part-time job soon."

"I didn't realize how sick I could get from a chemical brain imbalance."

A client with a 5-year history of multiple psychiatric admissions is brought to the emergency department by the police. This client was found wandering the streets disheveled, shoeless, and confused. The client points to the police officer and states, "That person was sent by the devil to kill me." Which response by the nurse is best? "No. That is untrue. That person is a police officer and is here to help you." "Try to ignore the police officer. Come sit down, and we can get you something to eat." "That sounds scary. That person is a police officer and brought you to the hospital." "I have taken care of lots of clients who felt the same way. The feeling will pass."

"That sounds scary. That person is a police officer and brought you to the hospital."

A 42-year-old female who comes to the clinic frequently for symptoms of neck pain is upset because there is no medical cause for the discomfort. Select the intervention(s) the nurse would take to help meet the client's needs. Select all that apply. Acknowledge the client's pain Ask what helps relieve the pain Provide teaching about phantom pain Review activities to use as a distraction Suggest the client ignore the discomfort Encourage participation in groups of interest Remind the client that there is no reason for the pain

Acknowledge the client's pain Ask what helps relieve the pain Review activities to use as a distraction Encourage participation in groups of interest

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.

The nurse is planning care for a client who has been experiencing a manic episode for 6 days and is unable to sit still long enough to eat meals. Which choice will best meet the client's nutritional needs at this time? a green salad topped with chicken pieces a peanut butter sandwich a bowl of vegetable soup favorite foods from home

a peanut butter sandwich

The nurse is caring for a client on the psychiatric unit. The client states, "The voices are bothering me. They are yelling and telling me stuff. They are really bad." Which responses by the nurse would be most appropriate? "Do you hear these voices very often?" "Do you have a plan for getting away from the voices?" "I do not hear any voices. What are you hearing?" "Try to ignore them and play cards with the others."

"I do not hear any voices. What are you hearing?"

The client tells the nurse that they stopped taking olanzapine 2 weeks ago because they are better and want "to make it on my own without this darned medicine." What would be the nurse's most therapeutic response? "You've told me about other times like this when you stopped taking your medication and you got sick again. You should know better by now." "You're a smart person. You know what will happen if you don't take your medication. Why do you want to stop?" "I know you get tired of taking the medication, especially when you are doing well. Is there any special reason you decided to stop right now?" "Maybe you're ready for a short holiday from the olanzapine. I'll talk it over with your health care provider. But you need to keep taking it until then."

"I know you get tired of taking the medication, especially when you are doing well. Is there any special reason you decided to stop right now?"

A client taking clozapine states, "I don't like feeling so sedated during the day. I can hardly keep my eyes open." Which response by the nurse would be most appropriate? "Try waking up an hour earlier to see if that helps." "Sleep as long as you need to and nap fairly often." "Let's talk to your health care provider about taking most of the drug at bedtime." "Going to bed earlier at night might help."

"Let's talk to your health care provider about taking most of the drug at bedtime."

A client tells a 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?" "There are no people living on Mars." "What do you mean when you say they're going to invade the Earth?" "I know you believe the Earth is going to be invaded, but I don't believe that."

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

A client with schizophrenia repeatedly uses profanity during an activity therapy session. Which response by the nurse is appropriate? "Your behavior won't be tolerated. Go to your room immediately." "You're just doing this to get back at me for making you come to therapy." "Your cursing is interrupting the activity. Take time out in your room for 10 minutes." "I'm disappointed in you. You can't control yourself for even a few minutes."

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

What action should the nurse take when a client with a diagnosis of schizophrenia walks into group naked? Instruct the client to go to their room and put on some clothes. Wrap a blanket around them and tell them to be seated for the remainder of group. Ask a male client to take off their sweater and wrap it around the client's waist. Lead the client to their room and help him dress if they need assistance.

Lead the client to their room and help him dress if they need assistance.

A nurse is caring for a client admitted with arching of the back, extension and rotation of the neck, and slow involuntary contractions of the arms and neck. After review of the client's medication list, the nurse would be correct in associating these symptoms with which medication? benztropine pantoprazole propranolol haloperidol

haloperidol

The nurse is instructing the client who has a prescription for lurasidone HCL for schizoaffective disorder. Which nursing instruction is most appropriate? "Take the dose: in the morning with a full breakfast of eggs, toast, juice, and coffee." in the evening with a sandwich and a glass of milk." at noon with an apple and celery." in the midafternoon with water."

in the evening with a sandwich and a glass of milk."

The nurse is providing discharge teaching to a client diagnosed with schizophrenia. Which client statement(s) would cause the nurse to intervene? Select all that apply. "As soon as I start feeling like myself again, I'll decrease my medications." "I should look for a mental health support group." "I'll exercise 3 times a week and stop eating fast food." "If the voices come back, I'll stay at home to ensure my safety." "I'll call if I develop muscle twitches I can't control."

"As soon as I start feeling like myself again, I'll decrease my medications." "If the voices come back, I'll stay at home to ensure my safety."

A client with a chronic mental illness has worked as a hotel maid for the past 3 years. The client tells the nurse they are thinking of quitting the job because "voices on television are talking about me." What action should the nurse take first? Obtain information about the client's medication compliance. Remind the client that hearing voices is a symptom of their illness that they can cope with. Check with the client's employer about their work performance. Arrange for the client to be admitted to a psychiatric hospital for a short stay.

Obtain information about the client's medication compliance.

Which finding indicates that a client with bipolar disorder, manic phase, is nearing readiness for discharge? sleeping 4 hours per night differentiating realistic self-image from grandiosity suddenly telephoning their spouse and asking for a divorce demonstrating a labile affect

differentiating realistic self-image from grandiosity

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 charge nurse is educating a new nurse on antipsychotic medications. The charge nurse knows teaching has been effective when the new nurse makes which statement? "Antipsychotic medication stops the breakdown of monoamine neurotransmitters, which keep the brain's concentration of neurotransmitters steady." "Antipsychotic medication blocks the effect of acetylcholine at the myoneural junction." "Antipsychotic medication depresses the central nervous system by blocking the postsynaptic transmission of dopamine, serotonin, and norepinephrine." "Antipsychotic medication binds to opiate receptors in the central nervous system and alters the response to pain."

"Antipsychotic medication depresses the central nervous system by blocking the postsynaptic transmission of dopamine, serotonin, and norepinephrine."

A client with chronic schizophrenia has received 10 mg of fluphenazine hydrochloride PO q.i.d. Now the client has a temperature of 102° F (38.9° C), a heart rate of 120 beats/minute, a respiratory rate of 20 breaths/minute, and a blood pressure of 210/140 mm Hg. Because the client is also confused and incontinent, the nurse suspects neuroleptic malignant syndrome. What steps should the nurse take? Give the client the next dose of fluphenazine, call the physician, and monitor the client's vital signs. Withhold the client's next dose of fluphenazine, call the physician, and monitor the client's vital signs. Give the client the next dose of fluphenazine and restrict the client to an empty room to decrease stimulation. Withhold the client's next dose of fluphenazine, administer an antipyretic agent, and increase the client's fluid intake.

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

A nurse is reviewing the medication list of a client who presents with slow, involuntary muscle spasms of the arms and legs and twisting of the neck. The nurse reviews the client's prescriptions for which medication that could correlate with these symptoms? diazepam haloperidol amitriptyline hydrochloride clonazepam

haloperidol

A client with schizophrenia tells the nurse that they do not go out much because they don't have anywhere to go, and they do not know anyone in the apartment building where they are staying. Which action is most beneficial for the client at this time? encouraging them to call their family to visit more often making an appointment for the client to see the nurse daily for 2 weeks thinking about the need for rehospitalization for the client arranging for the client to attend day treatment at the clinic

arranging for the client to attend day treatment at the clinic

A 23-year-old client diagnosed with schizophrenia cheerfully announces, "My parents and I are so excited that I'm pregnant. They're willing to help us take care of the baby too." Which reason should cause the nurse to be concerned about this situation? The client did not say that the father of the baby was excited about this. The client's parents are not likely to provide enough help for what the client needs. Symptom management will be difficult in early pregnancy without medications. The client will have difficulty financially supporting the baby.

Symptom management will be difficult in early pregnancy without medications.

A nurse is caring for a client receiving a dopamine receptor agonist for treatment of extrapyramidal symptoms caused by antipsychotic medications. What evaluation would indicate a therapeutic response to this drug? Client exhibits bradyphrenia during the nursing assessment. Client exhibits a shuffling gait with stooped posture. Client exhibits akathisia only while sitting. Client experiences a decrease in dystonia.

Client experiences a decrease in dystonia.

A client with schizophrenia hears a voice saying the client is evil and must die. The nurse understands that this client is experiencing: a delusion. flight of ideas. ideas of reference. a hallucination.

a hallucination.