Schizophrenia

A client hears voices telling him that he is a terrible person who wold be better off dead. What would be a priority nursing diagnosis for the nurse to select for the care plan? a. impaired verbal communication b. risk for violence, self-directed c. impaired sensory perception d. impaired social interatction

b. risk for violence, self-directed

A nurse performs an Abnormal Involuntary Movement Scale assessment on a client who began taking loxapine 2 years ago for the treatment of schizophrenia. Findings include lip smacking, tongue protrusion, and facial grimacing. The nurse should suspect which of the following? a. parkonsonism b. tardive dyskinesia c. anticholinergic effects d. akathisia

b. tardive dyskinesia

A charge nurse is discussing manifestations of schizophrenia with a newly licensed nurse. Which of the following should the charge nurse identify as being effectively treated by conventional antipsychotics? (select all) a. auditory hallucinations b. withdrawal from social situations c. delusions of grandeur d. severe agitation e. anhedonia

Conventional antipsychotics are used to treat positive symptoms of schizophrenia a. auditory hallucinations c. delusions of grandeur d. severe agitation b and e are negative symptoms

A nurse is preparing to perform a follow-up assessment on a client who takes chlorpromazine (Thorazine) for the treatment of schizophrenia. The nurse should expect to find the greatest improvement in which of the following manifestations? (select all) a. disorganized speech b. bizarre behavior c. impaired social interactions d. hallucinations e. decreased motivation

a b d conventional antipsychotics treat positive symptoms of schizophrenia

A client who is receiving thioridazine (Mellaril) 100mg tid comes to the clinic with the cc of a "dry mouth". To what should the nurse conclude this side effect is related? a. anticholinergic effects b. extrapyramidal side effects c. weight loss d. neuroleptic malignant syndrome

a. anticholinergic effects

A nurse is completing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms? (select all) a. auditory hallucination b. lack of motivation c. use of clang associations d. delusion of persecution e. constantly waving arms f. flat affect

a. auditory hallucination c. clang associations d. delusion persecution e. waving arms b. negative symptom f. negative symptom

A client with schizophrenia is exhibiting delusions, hallucinations, minimal self care, and hyperactive behavior. Which of these observations would the nurse document as a negative symptoms of schizophrenia? a. minimal self care b. delusions c. hallucinations d. inappropriate affect

a. minimal self care

A nurse is caring for a client who as a substance-induced psychotic disorder and is experiencing auditory hallucinations. The client states, "the voices won't leave me along!" Which of the following statements by the nurse are appropriate? (select all) a. when did you start hearing the voices b. the voices are not real, or else we would both hear them c. it must be scary to hear voices d. are the voices telling you to hurt yourself? e. why are the voices talking to only you

a. start hearing voices c. scary to hear voices d. hurt self b. do not argue with the patient e. never ask why

A nurse is caring for a client who has schizoaffective disorder. Which of the following statements indicates the client is experiencing depersonalization? a. I am a superhero and am immortal b. I am no one, and everyone is me c. I feel monsters pinching me all over d. I know that you are stealing my thoughts

b. I am no one, and everyone is me a. delusion of grandeur c. tactile hallucination d. withdrawal

The nurse is conducting medication teaching with a client about clozapine (Clozaril). The nurse should include information about what weekly intervention? a. physical exam b. hematological monitoring c. visit to physician d. urinalysis

b. WBC count weekly

A nurse is speaking with a client who has schizophrenia when he suddenly seems to stop focusing on the nurse's questions and begins looking at the ceiling and talking to himself. Which of the following actions should the nurse take? a. stop the interview, and resume later when the client is able to concentrate better b. ask the client, "are you seeing something on the ceiling? c. tell the client, "you seem to be looking at something on the ceiling. I see something there, too." d. continue the interview without comment on the client's behavior

b. ask the client directly to assess for a potential risk for injury

A nurse is teaching a client who has schizophrenia strategies to cope with anticholinergic effects of fluphenazine. Which of the following should the nurse suggest to the client to minimize anticholinergic effects? a. take the medication in the morning to prevent insomnia b. chew sugarless gum to moisten the mouth c. use cooling measures to decrease fever d. take an antacid to relieve nausea

b. chew sugarless gum

A nurse is assessing a client who is currently taking perphenazine. Which of the following findings should the nurse identify as an extrapyramidal symptom? (select all) a. decreased LOC b. drooling c. involuntary arm movements d. urinary retention e. continual pacing

b. drooling c. arm movements e. pacing a. is an indication of neuroleptic malignant syndrome d. is an anticholinergic effect

The nurse would conclude that a client with schizophrenia is exhibiting positive symptoms of the disorder after noting that the client does which of the following? (select all) a. exhibits lack of energy b. states he is a king c. repeats words the nurse says d. has a flat affect e. withdraws from other people

b. he is a king c. repeats words the nurse says a, d and e are negative effects

A nurse is assessing a male client who recently began taking haloperidol (Haldol). Which of the following findings is the highest priority to report to the provider? a. shuffling gait b. neck spasms c. drowsiness d. impotence

b. neck spasms are an indication of acute dystonia which is a crisis situation requiring rapid treatment All others are not the priority

A nurse is caring for a client on an acute mental health unit. The client reports hearing voices that are telling her to "kill your doctor". Which of the following is the priority action for the nurse to take? a. use therapeutic communication to discuss the hallucination with the client b. initiate one-to-one observation of the client c. focus the client on reality d. notify the provider of the client's statement

b. one-to-one observation client safety is the priority here

A client with schizophrenia has been taking haloperidol (Haldol) for three weeks with good effect. Today, he comes to group, but is complaining of feeling like his legs are on fire. The nurse notes that he is moving continuously and leaves group early. The nurse should document and report that the client is experiencing which medication side effect? a. anticholinergic effects b. gustatory hallucinations c. akathisia d. oculogyric crisis

c. akathisia is the uncontrollable need to move

The nurse is making a plan of care for a client who is Rx fluphenazine (Prolix) 1mg daily at bedtime. The nurse will include which intervention for the side effects of the medication? a. remind the client to rise slowly when getting out of bed b. assess for dizziness or lightheadedness frequently c. make sugarless gum/hard candy and water available d. monitor frequently for manifestations of confusion

c. anticholinergic effects

A nurse is caring for a client who takes ziprasidone (Geodon). The client reports difficulty swallowing the oral medication and becomes extremely agitated with injectable administration. The nurse should contact the provider to discuss a change to which of the following medications? (select all) a. olanzapine (Zyprexa) b. quetiapine (Seroquel) c. aripiprazole (Abilify) d. clozapine (Clozaril) e. paliperidone (Invega)

c. available in ODT d. available in ODT a, b, and e are only available in tablet/injectable forms

A client living in an assisted living facility is taking conventional antipsychotic medications. One evening the nurse notices that the client is experiencing muscle rigidity, confusion, delirium, and has a temp of 104. The nurse interprets these as symptoms of which adverse drug effect? a. dystonia b. akathisia c. neuroleptic malignant syndrome d. tardive dyskinesia

c. neuroleptic malignant syndrome

A 21 year old male college student who has become increasingly suspicious of others has accused a professor of conspiring with two other classmates to get him expelled from school. The client is admitted to a psychiatric unit after telephoning and threatening to kill the professor and his classmates. The client states, "they are all out to get me expelled. I think they are even trying to kill me. I have to stop them." What would be a therapeutic appropriate response by the nurse? (select all) a. why do you think they are out to get you expelled or to kill you b. it is difficult to believe that your professor and classmates are out to get you expelled or to kill you c. it's not right to kill others even if they are out to get you expelled or want to kill you d. your professor and classmates are not out to get you expelled or kill you, let's look at the facts e. it must be frightening to think that others are out to kill you or cause you some type of harm

c. not ok to kill others e. frightening to think others are out to get you

A nurse is caring for a client who has schizophrenia and exhibits a lack of grooming and a flat affect. The nurse should anticipate a Rx for which of the following medications? a. chlorpromazine (Thorazine) b. thiothixene (Navane) c. risperidone (Risperdal) d. haloperidol (Haldol)

c. risperidone (Risperdal) - effective in treating negative symptoms a. chlorpromazine used to control positive symptoms b. thiothixene used to control positive symptoms d. haloperidol used to control postive symptoms

A nurse is providing dc teaching for a client who has schizophrenia and a new Rx for iloperidone (Fanapt). Which of the following client statements indicates understanding of the teaching? a. I will be able to stop taking this medication as soon as I feel better b. If I feel drowsy during the day, I will stop taking this medication and call my provider c. I will be careful not to gain too much weight while taking this medication d. This medication is highly addictive and must be withdrawn slowly

c. weight gain

A nurse is providing dc teaching for a client who has a new Rx for clozapine (Clozaril). Which of the following statements is appropriate for the nurse to include in the teaching? a. you should have a high-carbohydrate snack between meals and at bedtime b. you are likely to develop hand tremors if you take this medication for a long period of time c. you may experience temporary numbness of your mouth after each dose d. you should have your white blood cell count monitored every week

d. WBC weekly a. clozapine increased risk for developing DM and wt. gain. No increased carbs. b. clozapine low risk for EPS c. asenapine caused numb mouth

A client states that he is able to receive radio waves from aliens because they placed a computer chip in his brain. The nurse would document this behavior as which of the following? a. hallucination b. reality orientated c. an illusion d. delusion

d. delusion

A client, admitted to the inpatient unit with a dx of paranoid schizophrenia, is prescribed resperidone (Risperdal). After 5 days of treatment, the client reports feeling dizzy. What should the nurse explain to the client is associated with this manifestation? a. the desired effect of sedation b. loss of appetite c. anticholinergic effects d. orthostatic hypotension

d. orthostatic hypotension