Psychotic Disorders
A more experienced nurse is attempting to help a newly hired nurse gain a better understanding of delusions. Which statement, provided by the experienced nurse, would correctly explain behavior that represents a client's delusion?
"A client tells you, the FBI is monitoring conversations through the IUD (intrauterine device)."
A client tells the nurse that a voice keeps telling him to crawl on his hands and knees like a dog. Which response by the nurse is most appropriate for this client?
"Even though I don't hear the voices, I understand that you do."
A client approaches the nurse and points at the sky, showing the nurse where the scary men would be coming from to get them. Which response is most therapeutic?
"It seems like the world is pretty scary for you, but you're safe here."
A nurse is reinforcing the teaching plan with a client diagnosed with dissociative identity disorder (DID). Which statement by the client indicates that the education has been effective?
"My brain has temporarily hidden my memories of the rape to protect me."
A client asks a nurse, "Do you hear the voices speaking to me?" Which response by the nurse is best?
"No, I don't hear anything, but I know you do. What are they saying?"
While interacting with a client with dissociative identity disorder (DID), a nurse observes characteristics of an alter personality. The client goes from being calm to being angry and shouting. Which response would be most appropriate?
"Tell me how you are feeling right now."
A client with dissociative amnesia says, "You must think I'm really stupid because I have no recollection of the accident." Which response would be most appropriate?
"The brain sometimes protects us by not letting us remember traumatic events."
A client is prescribed haloperidol. When reinforcing the teaching plan about the drug, which instruction would the nurse emphasize?
"You should report feelings of restlessness or agitation at once."
The nurse is gathering information from a client with schizophrenia. The client states, "I am being poisoned by the staff here. I will not eat food or drink any liquids that they give me. They are trying to kill me!" What is the best response by the nurse?
"You sound upset. Would you like to discuss this further?"
A client with schizophrenia repeatedly uses profanity during an activity therapy session. Which response by the nurse would be appropriate?
"Your cursing is interrupting the activity. Take time out in your room for 10 minutes."
A nurse finds a suicidal client trying to hang themself with a belt. In order to preserve self-esteem and safety, what action should the nurse take?
Assign a nursing staff member to remain with the client at all times.
A nurse observes that an alternate personality (a child) of an adult client with dissociative identity disorder (DID) is in control. The client is sitting in the dayroom, interacting with others. Which action would be most appropriate?
Remove the client from the dayroom and reorient in a safe place.
The nurse is planning care for a paranoid client admitted to the psychiatric unit with a diagnosis of schizophrenia. Which nursing diagnosis should receive the highest priority?
Risk for self- or other-directed violence
The etiology of schizophrenia is best described by:
a combination of biological, psychological, and environmental factors.
A client with schizophrenia hears a voice telling him he is evil and must die. The nurse understands that the client is experiencing:
a hallucination.
A client with depersonalization/derealization disorder is prescribed drug therapy as part of the treatment plan. Which medication would the nurse most likely administer if prescribed? (Select all that apply.)
alprazolam lorazepam clonazepam
A client with schizophrenia was admitted to the psychiatric unit during the night. The next morning, the client begins to call the nurse by a sister's name. Which intervention is best?
correcting the misidentification and orienting the client to the unit and staff
A client is admitted after being found on a highway, throwing rocks and debris and yelling at motorists. When approached by the nurse, the client shouts, "You're the one who stole my husband from me." The nurse interprets the client's statement as indicating which condition?
delusional experience
A nurse is reviewing the interdisciplinary plan of care for a client experiencing hallucinations. Which intervention would the nurse most likely identify as being included in the plan?
providing a competing stimulus that distracts from the hallucinations
A client has been receiving chlorpromazine to treat psychosis. Which findings would the nurse immediately report to the supervising nurse that demonstrate the client is experiencing pseudoparkinsonism? (Select all that apply.)
tremors shuffling gait masklike face
The nurse is gathering data from a client with dissociative identity disorder (DID). What statement by the client would the nurse expect to hear?
"I can't recall certain events or experiences."
A client with a history of schizophrenia is having hallucinations. The client shouts to the nurse, "You're stepping on spiders! Move aside. Don't you see them?" Which response by the nurse would be best?
"I don't see them, but I know you believe you do."
A 54-year-old client who was admitted to the psychiatric unit during an acute phase of schizophrenia has hardly eaten and hasn't bathed or changed his clothes for 3 weeks. He undergoes 4 weeks of psychotherapy and medication adjustment. Which statement by the client indicates that he's ready for discharge?
"I know a sign of my disease is not bathing and maintaining my personal appearance."
A 45-year-old client with schizophrenia expresses a fear of sleeping because voices become threatening when she attempts to sleep. To avoid sleeping the client reports drinking 40 cups of coffee a day. Which response by the nurse is appropriate?
"I know that you're afraid to sleep; let's discuss the effect of caffeine on your voices."
A client was the driver in an automobile accident in which a 3-year-old was killed; the client is now experiencing dissociative amnesia. After reviewing the treatment plan with the client, the nurse determines that the client demonstrates understanding by which statement?
"I'll attend my hypnotic therapy sessions prescribed by my psychiatrist."
While pacing in the hall, a client with schizophrenia runs to the nurse and says, "Why are you poisoning me? I know you work for central thought control! You can keep my thoughts. Give me back my soul!" How should the nurse respond during the early stage of the therapeutic process?
"I'm a nurse, and you're a client in the hospital. I'm not going to harm you."
A client was hospitalized after a family member filed a petition for involuntary hospitalization for safety reasons. The family member seeks out the nurse because the client is angry and refuses to talk. The family member states, "I feel so guilty about my decision." Which response by the nurse is the most empathic?
"It's common for family members to feel this way. Can you tell me more?"
A client tells the 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?"
A client experiencing paranoid delusions states, "They are conspiring against me; they're after me all night." Which response by the nurse would be the most empathic?
"That sounds frightening."
Since admission 4 days ago, a client has refused to take a shower, stating, "There are poison crystals hidden in the showerhead. They'll kill me if I take a shower." Which action is most appropriate?
Accept the client's fears, allowing the client to take a sponge bath.
Since admission 4 days ago, a client has refused to take a shower, stating, "There are poison crystals hidden in the showerhead. They'll kill me if I take a shower." Which action is mostappropriate?
Accept the client's fears, allowing the client to take a sponge bath.
The nurse is caring for a client who has schizophrenia. What is the first-line treatment for this client?
Antipsychotics
A client with dissociative identity disorder (DID) requires hospitalization. Which intervention would most likely appear in the client's plan of care plan?
Arrange to have staff check on the client every 15 to 30 minutes.
A client with schizophrenia reports that hallucinations have decreased in frequency. Which intervention would be appropriate to begin addressing the client's problem with social isolation?
Ask the client to participate in a group sing-along.
A client is admitted to the emergency department frightened and reports hearing voices with instructions to do bad things. Which intervention should be the nurse's priority?
Assess the nature of the commands by asking the client what the voices are saying.
A nurse is caring for a newly admitted client diagnosed with schizophrenia and is started on antipsychotic medication. When reviewing the client's file, which notation would alert the nurse to notify the health care provider before implementing?
Client is scheduled to have a myelogram within 48 hours of admission.
The physician prescribes loxapine, 50 mg by mouth twice per day. The client requires the liquid form of the drug. Which action should the nurse take before administering the drug?
Dilute the liquid concentrate with orange or grapefruit juice.
A 62-year-old male client with schizophrenia tells a nurse that he sexually molests his cousin. He tells the nurse that he's never told anyone and begs her to keep his secret. Which action should the nurse take?
Document the details of the conversation and notify the nursing supervisor.
Which nursing intervention would be the priority when caring for a client with a dissociative disorder?
Encouraging the client to participate in unit activities and meetings
A client states to the nurse, "The voices are telling me to do terrible things." As part of the client's initial therapy, which action would be most likely included?
Find out what the voices are saying.
While reviewing the mental health chapter, which symptoms does the nursing student identify as the positive symptoms of schizophrenia?
Hallucinations, delusions, and disorganized thinking
A dystonic reaction can be caused by which medication?
Haloperidol
A nurse on a psychiatric unit observes a client in the corner of the room moving their lips as if they were talking to themselves. Which action is the most appropriate?
Invite the client to join in a card game.
The nurse is providing care to a client who has just had an episode of dissociative fugue. Which nursing intervention would be most appropriate for this client?
Let the client verbalize the fear and anxiety the client feels.
The nurse is assigned to a client with schizophrenia who is experiencing catatonia. Which intervention should the nurse include in the client's plan of care?
Meeting all of the client's physical needs
A client with chronic schizophrenia who takes neuroleptic medication is admitted to the psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, tachycardia, altered consciousness, and diaphoresis. These findings suggest which life-threatening reaction?
Neuroleptic malignant syndrome
A client who's taking antipsychotic medication develops a very high temperature, severe muscle rigidity, tachycardia, and rapid deterioration in mental status. The nurse suspects what severe complication of antipsychotic therapy?
Neuroleptic malignant syndrome (NMS)
The nurse is caring for a schizophrenic client who becomes violent and delusional. Which therapeutic actions are best? (Select all that apply.)
Obtain additional staff assistance as needed. Ensure the safety of the client and others in the area. If restraints are required, explain what is being done and why.
A 36-year-old client with a history of schizophrenia is admitted to the emergency department with a fever of 102° F (38.9° C), severe headache, photophobia, nuchal rigidity, and nausea. A physician believes that a lumbar puncture is necessary to help confirm his suspicions of meningitis. The nurse is asked to witness the informed consent. How can the nurse best assess the client's mental status before witnessing the consent?
Perform a brief mental status examination to determine whether the client is oriented to person, place, time, and purpose.
A nurse is interacting with a client with a dissociative identity disorder. During the interaction, the nurse observes that one of the alter personalities is in control. Which intervention is mostappropriate?
Recognize the alter personality.
During a conversation with a client, the nurse recognizes a delusion of persecution. What is the priority action by the nurse?
Redirect the conversation back to reality.
A client in the behavioral health unit with a history of noncoercive paraphilia is experiencing an auditory hallucination. What is the priority nursing action?
Stay with the client.
A nurse is caring for a client with a diagnosis of dissociative identity disorder (DID). Which client behavior should the nurse identify as a safety risk?
The client expresses a desire to do self harm.
The nurse is preparing to administer chlorpromazine to a client with schizophrenia. Which circumstance, if noted in this client's history, would cause the nurse to notify the health care provider for accuracy of the prescription?
The client is also receiving labetalol.
The nurse is preparing to administer chlorpromazine to a client with schizophrenia. Which circumstance, noted in the client's history, would cause the nurse to notify the health care provider for accuracy of the prescription?
The client is also receiving labetalol.
A client states to the nurse, "I was watching television and the person in the commercial was trying to send me a message to be careful about who I talk with in this place because they will betray me." What behavior disturbance is the client displaying to the nurse?
The client is having delusions of reference.
Teaching for women in their childbearing years who are receiving antipsychotic medications should include which of the following facts?
The client should continue using contraception during periods of amenorrhea.
The nurse is working as part of the interdisciplinary team in caring for a client with dissociative identity disorder. Which behavior reported by a family member would indicate that the client's therapy is effective?
The client sleeps through the night.
A client who is preparing for discharge to a halfway house must be referred to an outpatient clinic. Which criteria should be considered when choosing an outpatient treatment program for this client?
The clinic is within walking distance, and a staff member will send a caseworker to the halfway house to assess the client and develop a treatment plan.
While reading a journal article, a nurse comes across a discussion of the causes of dissociative disorders. Which information would the nurse most likely find in the discussion?
They occur as a result of the brain trying to protect the person from severe stress.
A client is prescribed fluphenazine hydrochloride, 10 mg by mouth daily in divided doses. The pharmacy sends liquid concentrate for the client because he has difficulty swallowing tablets. Which precaution should the nurse take when administering this medication?
Wear gloves when preparing the solution and avoid having the drug contact the skin.
For several years, a client with chronic schizophrenia has received 10 mg of fluphenazine hydrochloride by mouth four times per day. 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 also is confused and incontinent, the nurse suspects malignant neuroleptic syndrome. What steps should the nurse take?
Withhold the next dose of fluphenazine, call the physician, and monitor vital signs.
A client is admitted to the psychiatric unit with a tentative diagnosis of psychosis. Her physician prescribes 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 calming effect from which the client is easily aroused.
A client is being treated at a community mental health clinic. A nurse has been instructed to observe for any behaviors indicating dissociative identity disorder (DID). Which behavior would be included?
changes in dress, mannerisms, and voice
An adolescent child of a parent with schizophrenia is worried thet might have schizophrenia as well. Based on the nurse's understanding of the disorder, which behavior would be an indication that the child should be evaluated for signs of the disorder?
changes in sleep patterns
A client is referred to a mental health clinic by the court for harassing a couple next door and claiming that the husband was in love with her. She wrote love notes and called him on the telephone throughout the night. The client is employed and has had no problems with her job. The nurse interprets these findings as suggesting which condition?
delusional disorder
A client lost his home in a flood last month. When questioned about feelings about the loss, there is no memory of being in a flood or owning a home. Based on the client's report, the nurse suspects that the client is most likely experiencing which condition?
dissociative amnesia
A client is admitted to the psychiatric unit with active psychosis. The physician diagnoses schizophrenia after ruling out several other conditions. Schizophrenia is characterized by:
disturbances in affect, perception, and thought content and form.
A client with a history of bipolar disorder came to the hospital with an exacerbation. The client has been prescribed lithium and has not taken it for the past 2 weeks. What finding is the nurse likely observe?
flight of ideas
A nurse is collecting data from a client diagnosed with schizophrenia. Which symptoms would the nurse identify as supporting the client's diagnosis?
hallucinations or delusions and decreased ability to function in society
A client diagnosed with schizophrenia several years ago tells the nurse about feeling "very sad." The nurse observes that the client is smiling when saying it. When documenting this observation, the nurse would describe it using which term?
inappropriate affect
While providing care to a client receiving antipsychotic therapy, the nurse suspects that the client is experiencing tardive dyskinesia based on which finding?
involuntary movements
A client with schizophrenia tells the nurse he hears the voices of his dead parents. To help the client ignore the voices, the nurse should recommend that he:
listen to a personal stereo through headphones and sing along with the music.
The nurse is caring for a client diagnosed with schizophrenia. The client says, "The earth and the roof of the house rule the political structure with particles of rain." The nurse interprets this statement as which type of expression?
loose association
A nurse is carrying out the plan of care developed for a client diagnosed with dissociative identity disorder (DID). Which intervention would be the priority for this client?
maintaining consistency when interacting with the client
A nurse is implementing interventions for the care of a client admitted with a diagnosis of schizotypal personality disorder. Which behavior would the nurse most likely observe in the client during this situation?
paranoid thoughts
A nurse is caring for a client with dissociative amnesia who is exhibiting signs of low self-esteem. The nurse determines that the interventions have been successful when the client demonstrates which behavior?
participation in new activities
A client with depersonalization/derealization disorder spends much of the day in a dreamlike state, ignoring personal care needs. What situation is this behavior most likely related to?
perceptual impairment
The nurse is reviewing a nursing care plan for a client with a psychophysiologic disorder. Nursing interventions should address which symptoms?
physical symptoms as well as psychosocial and spiritual problems
The nurse is reviewing the plan of care for a client diagnosed with schizophrenia who has just been admitted to the psychiatric unit. Which intervention would the nurse identify as the priority for this client?
providing a consistent, predictable environment
An agitated and incoherent client, age 29, comes to the emergency department and reports having visual and auditory hallucinations. The history reveals that the client was hospitalized for schizophrenia from ages 20 to 21. The physician prescribes haloperidol, 5 mg I.M. The nurse understands that this drug is used in this client to treat:
psychosis
An adolescent client with a diagnosis of schizophrenia has become very clingy and begins sucking their thumb while interacting with the nurse. The nurse understands that these behaviors indicate which defense mechanism?
regression
Hormonal effects of the antipsychotic medications include:
retrograde ejaculation and gynecomastia.
A nurse is providing care to a client with delusional disorder who has been admitted to the inpatient psychiatric unit. The client states, "I can't stand this itching and burning any more. All these bugs are crawling all over my skin. See, it's like they're swarming all around me and drilling holes in my skin." On inspection, the skin is clean, dry and intact without any evidence of redness or irritation. The nurse suspects that the client is experiencing which type of delusion?
somatic
A client states, "I can't eat because my bowels have turned against me." The nurse determines that the client is exhibiting which behavior?
somatic delusion
A client with dissociative disorder is hospitalized. The client has threatened to commit suicide. When gathering data from the client, which set of circumstances would the nurse identify as indicating the highest risk of suicide?
suicide plan, handy means of carrying out plan, and history of previous attempt
A client with schizophrenia is admitted to the psychiatric unit of a hospital. Data collection should include careful observation of the client's:
thinking, perceiving, and decision-making skills.
A client with dissociative identity disorder (DID) is admitted to an inpatient psychiatric unit. A nurse-manager asks all staff to attend a meeting. Which is the most likely reason for the meeting?
to allow staff members to discuss concerns about working with a client with DID
A client is admitted to the psychiatric hospital with a diagnosis of schizophrenia and who is experiencing catatonia. During the physical examination, the client's arm remains outstretched after the nurse obtains the pulse and blood pressure, and the nurse must reposition the arm. This client is exhibiting:
waxy flexibility.
