Psychotic Disorders
A newly admitted client diagnosed with paranoid schizophrenia is pacing rapidly and wringing his hands. He states that another client is out to get him. Then he says, "Protect me, select me, reject me." The nurse should next: A) Administer his oral PRN lorazepam (Ativan) and haloperidol (Haldol). B) Place the client in temporary seclusion before he has a chance to hurt others. C) Call the primary health care provider for a prescription for restraints. D) Ask the other clients to leave the immediate area.
A) Administer his oral PRN lorazepam (Ativan) and haloperidol (Haldol). Reason: The client's anxiety as reflected in rapid pacing and clang associations is rising as a result of his paranoid delusions. Administering the Ativan and Haldol will help the anxiety and delusions. He is not threatening others at this point, so seclusion, restraints, and asking clients to leave the area is not necessary.
At an outpatient visit 3 months after discharge from the hospital, a client says he has stopped his olanzapine (Zyprexa) even though it controls his symptoms of schizophrenia better than other medications. "I have gained 20 lb already. I can't stand anymore." Which response by the nurse is most appropriate? A) "I don't think you look fat, why do you think so?" B) "I can help you with a diet and exercise plan to keep your weight down." C) "You can be switched to another medicine." D) "Your weight gain will level off if you stay on the medication 3 more months."
B) "I can help you with a diet and exercise plan to keep your weight down." Reason: Helping the client control his weight is the most appropriate approach. The nurse's contradiction of the client's complaint is inappropriate. Most atypical antipsychotics cause weight gain and are not a solution to the weight gain. There is little evidence that weight gain from taking olanzapine decreases with time.
A client with bipolar disorder, manic phase, just sat down to watch television in the lounge. As the nurse approaches the lounge area, the client states, "The sun is shining. Where is my son? I love Lucy. Let's play ball." The client is displaying: A) Concreteness. B) Flight of ideas. C) Depersonalization. D) Use of neologisms.
B) Flight of ideas. Reason: The client is demonstrating flight of ideas, or the rapid, unconnected, and often illogical progression from one topic to another. Concreteness involves interpreting another person's words literally. Depersonalization refers to feelings of strangeness concerning the environment or the self. A neologism is a word made up by a client.
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: A) deeper sleep than CNS depressants. B) greater sedation than CNS depressants. C) a calming effect from which the client is easily aroused. D) more prolonged sedative effects, making the client more difficult to arouse.
C) a calming effect from which the client is easily aroused. Reason: Shortly after phenothiazine administration, a quieting and calming effect occurs, but the client is easily aroused, alert, and responsive and has good motor coordination.
A client has refused to take a shower since being admitted 4 days earlier. He tells a nurse, "There are poison crystals hidden in the showerhead. They'll kill me if I take a shower." Which nursing action is most appropriate? A) Dismantling the showerhead and showing the client that there is nothing in it B) Explaining that other clients are complaining about the client's body odor C) Asking a security officer to assist in giving the client a shower D) Accepting these fears and allowing the client to take a sponge bath
D) Accepting these fears and allowing the client to take a sponge bath Reason: By acknowledging the client's fears, the nurse can arrange to meet the client's hygiene needs in another way. Because these fears are real to the client, providing a demonstration of reality by dismantling the shower head wouldn't be effective at this time. Explaining that other clients are complaining about his body odor or asking a security officer to assist in giving the client a shower would violate the client's rights by shaming or embarrassing him.
The nurse should assess the client who is taking risperidone (Risperdal) 1 mg, orally twice a day for: A) Insomnia. B) Headache. C) Anxiety. D) Orthostatic hypotension.
D) Orthostatic hypotension. Reason: Significant orthostatic hypotension is associated with risperidone (Risperdal) therapy. The nurse should monitor the client's blood pressure sitting and standing and teach the client interventions to manage this adverse effect to prevent risk of injury. Although insomnia, headache, and anxiety are possible adverse effects of risperidone therapy, they are of less immediate concern than orthostatic hypotension.
A client with chronic undifferentiated schizophrenia is admitted to the psychiatric unit of a local hospital. During the next several days, the client is seen laughing, yelling, and talking to himself. This behavior is characteristic of: A) delusion. B) looseness of association. C) illusion. D) hallucination.
D) hallucination. Reason: Auditory hallucination, in which one hears voices when no external stimuli exist, is common in schizophrenic clients. Such behaviors as laughing, yelling, and talking to oneself suggest such a hallucination. Delusions, also common in schizophrenia, are false beliefs or ideas that arise without external stimuli. Clients with schizophrenia may exhibit looseness of association, a pattern of thinking and communicating in which ideas aren't clearly linked to one another. Illusion is a less severe perceptual disturbance in which the client misinterprets actual external stimuli. Illusions are rarely associated with schizophrenia.
