ch 16 NCLEX questions
A client diagnosed with schizophrenia tells the nurse, "I hear the voice of Elvis." Which is the most therapeutic response by the nurse? "You know that Elvis has been dead for years." "Don't worry about the voice as long as it doesn't belong to anyone real." "I don't hear the voice, but I know you hear what sounds like a voice." "You shouldn't focus on Elvis's voice."
"I don't hear the voice, but I know you hear what sounds like a voice." Rationale:Acknowledging that the client hears what sounds like a voice states reality about the client's hallucination. The other options are judgmental and demeaning.
A client tells the nurse that the client has bugs in the client's brain and asks the nurse if the nurse can see them. Which response by the nurse is most therapeutic? "No, I don't see any bugs. That sounds scary for you." "You have a thought disorder and only think you have bugs in your brain. There really aren't any. You don't have to worry because we would give you medicine for any medical problems." "No, I don't see any bugs. You seriously can't have any bugs in your brain." "Your thinking is a little illogical. I wouldn't be able to see bugs if they were inside your brain. Would you like to talk more about this?"
"No, I don't see any bugs. That sounds scary for you." Rationale:The person who hallucinates is preoccupied and frightened by what he or she hears or sees. The hallucination is real to the client, and the nurse cannot argue away, dismiss, or ignore it. Although the hallucination is real to the client, nurses make it clear that they do not hear the voices or see the visual images. Nurses do, however, communicate concern that the client is bothered, upset, or frightened by the hallucination.
A client diagnosed with schizophrenia has been prescribed clozapine. Which is a potentially fatal side effect of this medication? Dystonia Agranulocytosis Tardive dyskinesia Neuroleptic malignant syndrome
Agranulocytosis Rationale: Agranulocytosis is manifested by a failure of the bone marrow to produce adequate white blood cells. Neuroleptic malignant syndrome is a life-threatening reaction to neuroleptic medication that requires immediate treatment. Tardive dyskinesia causes involuntary movements of the tongue, mouth, facial muscles, and arm and leg muscles. Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles.
Which medication is used to control the extrapyramidal effects associated with antipsychotic medications? Thioridazine Haloperidol Chlorpromazine Benzotropine
Benzotropine Rationale: Benzotropine is an anticholinergic drug used to relieve drug-induced extrapyramidal adverse effects, such as muscle weakness, involuntary muscle movement, pseudoparkinsonism, and tardive dyskinesia.
Which medication classification has been most effective in treating akathisia? Sedatives Beta-blockers Antianxiety Antimanics
Beta-blockers Rationale:Beta-blockers, such as propranolol, have been most effective in treating akathisia.
What term is used to describe the speech pattern being used when the client imitates or repeats what the nurse is saying? Clang associations Echolalia Neologisms Word salad
Echolalia Rationale: Echolalia is the client's imitation or repetition of what the nurse says. Neologisms are words invented by the client. Clang associations are ideas that are related to one another based on sound or rhyming rather than meaning. A word salad is a combination of jumbled words and phrases that are disconnected or incoherent and make no sense to the listener.
A client diagnosed with schizoaffective disorder and severe depression is being treated with antipsychotic medications. The client tells the nurse about difficulty with self-care activities. With which intervention should the nurse respond? Gain assistance from family members. Contact the physician for a change in medications. Outline the side effects of the medications. Establish a routine and set goals.
Establish a routine and set goals. Rationale:The most useful approach for the nurse to try is to help the client establish a routine and set goals for accomplishing the activities of daily living.
How often must clients receiving clozapine get white blood cell counts drawn? Every 3 months Every year Every 6 months Every week for the first 6 months
Every week for the first 6 months Rationale: Clients taking clozapine must have weekly white blood cell counts for the first 6 months of clozapine therapy and every 2 weeks thereafter.
A married couple arrives at the outpatient clinic. Upon assessment, the nurse finds that the couple believes that the police have been following them and tapping their phones for 2 months. This couple most likely suffers from which disorder? Delusional disorder, paranoid type Folie à deux Psychotic disorder, not otherwise specified Conjugal delusion
Folie à deux Rationale:Shared psychotic disorder, or folie à deux, involves two individuals who have a close relationship and share the same delusion. This occurrence is attributed to the strong influence of the more dominant person. It is seen more frequently in women who are isolated by language, culture, or geography. Such persons are often related by blood or marriage and have lived together for an extended period of time. Contributing factors include old age, low intelligence, sensory impairment, cerebrovascular disease, and alcohol abuse. This disorder has been diagnosed in twins and individuals, both of whom had a chronic psychotic disorder. This disorder also has occurred in a group of individuals or in families in which the parent is the primary case (inducer).
A client with schizophrenia is hearing voices that tell the client to kill the self. What term is used to identify this type of false sensory perception? Delusion Ideas of reference Flight of ideas Hallucination
Hallucination Rationale: A hallucination is a sensory perception, such as hearing voices and seeing objects, that only the client experiences. A delusion is a false belief. Flight of ideas refers to a speech pattern in which the client skips from one unrelated subject to another. Ideas of reference refers to the mistaken belief that someone or something outside the client is controlling the client's ideas or behavior.
A client is watching the news and tells the nurse that the newscaster is sending a message to the client. What term is used to identify this symptom? Hallucination Idea of reference Delusion Flight of idea
Idea of reference Rationale:Ideas of reference refers to the mistaken belief that external events have special meaning to the individual, such as the television newscaster sending a message directly to the individual. A delusion is a false belief. A hallucination is a sensory perception, such as hearing voices and seeing objects, that only the client experiences. Flight of ideas is a speech pattern in which the client skips from one unrelated subject to another.
A client is being seen in the health clinic. The nurse observes a shuffling gait, drooling, and slowness of movement. The client is currently taking an antipsychotic for treatment of schizophrenia. The nurse knows that which side effect is occurring? Neuroleptic malignant syndrome Pseudoparkinsonism Dystonic movements Akathisia
Pseudoparkinsonism Rationale:Pseudoparkinsonism is exhibited by a shuffling gait, drooling, and slowness of movement. Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles. Akathisia causes restlessness, anxiety, and jitteriness. Neuroleptic malignant syndrome causes rigidity, fever, hypertension, and diaphoresis.
Which speech pattern is exhibited by the client stating, "I will take a pill if I go up the hill but not if my name is Jill, I don't want to kill?" Word salad Clang association Neologism Verbigeration
Rationale: Clang associations are ideas that are related to one another based on sound or rhyming rather than meaning. Neologisms are words invented by the client. A verbigeration is the stereotyped repetition of words or phrases that may or may not have meaning to the listener. A word salad is a combination of jumbled words and phrases that are disconnected or incoherent and make no sense to the listener.
The nurse suspects that a client is experiencing a brief psychotic episode based on what? Select all that apply. Recent life stressor Evidence of hallucinations Intense changes in affect Mild confusion Gradual onset of symptoms
Recent life stressor Evidence of hallucinations Intense changes in affect Rationale: In brief psychotic disorder, the length of the episode is at least 1 day but less than 1 month. The onset is sudden and includes at least one of the positive symptoms of criteria A for schizophrenia (delusions or hallucinations). The person generally experiences overwhelming confusion and rapid, intense shifts of affect. Brief psychotic disorder can often occur in the context of a recent life stressor such as giving birth.
A client who has a major depressive episode tells the nurse that, for the past 2 weeks, the client has been hearing voices and at times thinks that someone is following the client. A history reveals that the client has had these alternating symptoms before. The client also has experienced time with neither of these symptoms and has been able to function adequately. The nurse interprets these findings as suggesting: Paranoid schizophrenia Undifferentiated schizophrenia Schizoaffective disorder Brief psychotic disorder
Schizoaffective disorder Rationale:Schizoaffective disorder is characterized by intervals of intense symptoms between quiescent periods. At times, there are symptoms of schizophrenia, and at other times, there seems to be a mood disorder. Because the symptoms alternate with quiet periods, schizophrenia, either paranoid or undifferentiated, would not apply. A brief psychotic episode involves symptoms of at least 1 day but less than 1 month, and the onset is sudden. The client generally experiences emotional turmoil or overwhelming confusion and rapid intense shifts of affect.
When obtaining a client's history, a nurse determines that the client has been experiencing delusions and hallucinations for the past 3 months, which has caused some problems in the client's ability to function at work. The client also is exhibiting catatonic excitement, echopraxia, loose associations, and pressured speech. The nurse suspects which condition? Schizophrenia Brief psychotic disorder Schizoaffective disorder Schizophreniform disorder
Schizophreniform disorder Rationale:The essential features of schizophreniform disorder are identical to those of criteria A for schizophrenia (delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms), with the exception of the duration of the illness, which can be less than 6 months but with symptoms present for at least 1 month. Schizophrenia would be as described, but the symptoms must persist for at least 6 months. In brief psychotic disorder, the length of the episode is at least 1 day but less than 1 month. With schizoaffective disorder, the client must have an uninterrupted period of illness when there is a major depressive, manic, or mixed episode along with two of the following symptoms of schizophrenia: delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, or negative symptoms.
A client diagnosed with schizophrenia states to the nurse, "My intestines are being eaten by snakes." This statement represents which type of delusion? Referential delusion Somatic delusion Grandiose delusion Persecutory delusion
Somatic delusion Rationale:Somatic delusions are generally vague and unrealistic beliefs about the client's health or bodily functions. Persecutory delusions involve the client's belief that "others" are planning to harm the client or are spying, following, or belittling the client in some way. Grandiose delusions are characterized by the client's claim to associate with famous people or celebrities or the client's belief that he or she is famous or capable of great feats. Referential delusions or ideas of reference involve the client's belief that television broadcasts, music, or newspaper articles have special meaning for him or her.
A client has been taking neuroleptic medications for many years as a treatment for schizophrenia. The client is exhibiting tongue protrusion, facial grimacing, and excessive blinking. These manifestations are characteristic of which extrapyramidal side effects (EPS)? Dystonia Tardive dyskinesia Neuroleptic malignant syndrome Akathisia
Tardive dyskinesia Rationale:Unusual movements of the tongue, neck, and arms suggest tardive dyskinesia, an adverse reaction to neuroleptic medication. Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles. Neuroleptic malignant syndrome causes rigidity, fever, hypertension, and diaphoresis. Akathisia causes restlessness, anxiety, and jitteriness.
The nurse is evaluating the plan of care for a client with schizophrenia. Which observation best suggests that the plan has been effective? The client has resumed employment and attends social functions. The client no longer believes that the client has special powers. The client reports that the client no longer has hallucinations. The client has been engaging in more conversation with the staff.
The client has resumed employment and attends social functions. Rationale:Major goals for the care of a client with schizophrenia are to experience improved thought processes and fewer psychotic symptoms, to not engage in violent behavior, to acquire improved social skills and engage in satisfying social interaction, and to gain knowledge about the disease process and treatment. Increased conversations with the staff is unrelated to the overall plan of care for the client with schizophrenia.
A nurse who works in a psychiatry unit finds that young clients with schizophrenia have worse prognoses when compared with clients who are diagnosed later in life. Which reasons should lead the nurse to make this observation? Select all that apply. They have less sense of personal identity. They are less adherent to the treatment schedule. They are inherently more susceptible to a poor prognosis. They are less likely to have experiences of independent living. They are not able to accurately communicate their issues and concerns.
They have less sense of personal identity. They are inherently more susceptible to a poor prognosis. They are less likely to have experiences of independent living. Rationale:Young clients with schizophrenia have a poor prognosis when compared with older clients. Possible reasons include that young clients have a less developed sense of personal identity and have not had experiences of successful independent living. Differences in treatment adherence are not related to age. Difficulty in communicating problems does not depend on the age of the client. Age at onset appears to be an important factor in how well the client fares: those who develop the illness earlier show worse outcomes than those who develop it later.
A client diagnosed with schizophrenia states, "I want to go home, go home, go home." This is an example of which speech pattern? Word salad Verbigeration Neologisms Clang association
Verbigeration Rationale:A verbigeration is the stereotyped repetition of words or phrases that may or may not have meaning to the listener. Clang associations are ideas that are related to one another based on sound or rhyming rather than meaning. Neologisms are words invented by the client. A word salad is a combination of jumbled words and phrases that are disconnected or incoherent and make no sense to the listener.
Which is a nonneurologic side effect of antipsychotic medications? Dystonia Seizures Weight gain Akathisia
Weight gain Rationale: Weight gain is a nonneurologic side effect of antipsychotic medications.
A client is being released from the inpatient psychiatric unit with a diagnosis of schizophrenia and treatment with antipsychotic medications. After teaching the client and family about managing the disorder, the nurse determines that the education was effective when they state that which should be reported immediately? tremor weight gain elevated temperature decreased blood pressure
elevated temperature Rationale:Clients receiving antipsychotic therapy need to be alerted to the potential for complications, including neuroleptic malignant syndrome, a life-threatening condition that can occur with antipsychotic agents. This syndrome is manifested by severe muscle rigidity and elevated temperature that can rapidly accelerate. The nurse should instruct the client to seek immediate care if an elevated temperature develops. Tremor also should be reported, but this is not a life-threatening manifestation. Decreased blood pressure and weight gain can occur with antipsychotic agents, but these are not life threatening.
