Schizophrenia, MMD

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? a) "There is no need to be concerned about a man who isn't even real." b) "This subject seems to be troubling you. Let's walk to the activity room." c) "There is no reason to be afraid of that man. This hospital is very secure." d) "Describe the man who's out to get you. What does he look like?"

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

A client states, "The voices keep saying I am evil." Which outcome criteria is most important to include in the client's plan of care? 1. Demonstrates the ability to perceive the environment correctly 2. Uses appropriate verbal communication when interacting with others 3. Identifies factors that increase anxiety and illicit hallucinations 4. Demonstrates the ability to relate satisfactorily to others

3 The most important outcome is that the client can identify factors that increase anxiety and trigger hallucinations. Symptoms of psychosis may be minimized or prevented if the client learns techniques to interrupt escalating anxiety. Preventing symptoms is most important, as the client will be able to interpret the environment correctly when symptoms are managed.

A desired outcome for a client diagnosed with schizophrenia who has a nursing diagnosis of Disturbed sensory perception: auditory hallucinations related to neurobiological dysfunction would be that the client will A. ask for validation of reality. B. describe content of hallucinations. C. demonstrate a cool, aloof demeanor. D. identify prodromal symptoms of disorder.

A Beginning to question his or her own altered perceptions by seeking input from staff is highly desirable. Premorbid Prodromal Schizophrenia Residual

A client is admitted to the psychiatric unit with a diagnosis of major depression. The client is unable to concentrate, has no appetite, and is experiencing insomnia. Which should be included in this client's plan of care? A. A simple, structured daily schedule with limited choices of activities B. A daily schedule filled with activities to promote socialization C. A flexible schedule that allows the client opportunities for decision making D. A schedule that includes mandatory activities to decrease social isolation

ANS: A A client diagnosed with depression has difficulty concentrating and may be overwhelmed by activity overload or the expectation of independent decision making. A simple, structured daily schedule with limited choices of activities is more appropriate.

A client who has been taking buspirone (BuSpar) as prescribed for 2 days is close to discharge. Which statement indicates to the nurse that the client has an understanding of important discharge teaching? A. "I cannot drink any alcohol with this medication." B. "It is going to take 2 to 3 weeks in order for me to begin to feel better." C. "This drug causes physical dependence and I need to strictly follow doctor's orders." D. "I can't take this medication with food. It needs to be taken on an empty stomach."

ANS: B Buspar takes at least 2 to 3 weeks to be effective in controlling symptoms of depression. This is important to teach clients in order to prevent potential noncompliance due to the perception that the medication is ineffective.

A newly admitted male client with schizophrenia appears to be responding to internal stimuli when laughing and talking to himself. What is the best initial response by the nurse? Asking the client whether he is hearing voices Encouraging the client to engage in unit activities Telling the client that the voices he is hearing are not real Giving the client his prescribed PRN antipsychotic medication

Asking the client whether he is hearing voices Because the client is newly admitted, the nurse needs to conduct a thorough assessment before intervening. Encouraging the client to engage in unit activities may eventually be done but is not the priority. Telling the client that the voices he is hearing are not real assumes that the client is hallucinating. The client's behavior does not indicate the need for extra medication at this time. Some clients with schizophrenia have hallucinations throughout their lives.

A client asks the nurse why he has to go to therapy and cannot just take his prescribedantidepressant medication. Which would be the most therapeutic nursing intervention? A) Stating, The effects of medications will not last forever. You will need toeventually learn to function without them. B) Stating, Medications help your brain function better, but the therapy helps youachieve lasting behavior change. C) Stating, Both are recommended. Since your insurance covers both, that is the bestplan for you. D) Asking, Do you have reservations about going to therapy?î

B

The nurse observes a client sitting alone at a table, looking sad and preoccupied. Thenurse sits down and says, ìI saw you sitting alone and thought I might keep youcompany.î The client turns away from the nurse. Which would be the most therapeuticnursing intervention? A) Move to another chair closer to the client and say, The staff is here to help you. B) Move to a chair a little further away and say, We can just sit together quietly. C) Remain in place and say, How are you feeling today? D) Say, ìI'll visit with you a little later,î and leave the client alone for a while.

B

A client whose symptoms of schizophrenia are under control with olanzapine, and who is functioning at home and in her part-time employment, states that she is very concerned about her 20-lb (9.1-kg) weight gain since she started taking the medication 6 months ago. The nurse should: a) suggest that the client talk with her healthcare provider about changing to another antipsychotic. b) advise the client to decrease her dosage by one-half. c) discuss nutrition, daily diet, and exercise with the client. d) tell the client not to worry because she should stop gaining weight.

C

Which client is at highest risk for carrying out a suicide plan? A) A client who plans to take a bottle of sleeping pills. B) A client who says, My life is over. C) A client who has a private gun collection. D) A client who says, I'm going to jump off the next bridge

C) A client who has a private gun collection. While all statements indicate potential suicide risk, having access to a means of high lethality, such as a private gun collection, increases the immediate risk for completing suicide. Firearms are highly lethal, and access to them can make a suicide attempt more likely to result in a fatal outcome.

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. continue to work and recognize that these feelings are normal. ask the charge nurse if another, less-demanding assignment is available. talk with the charge nurse and seek support from peers on the unit.

Correct response: talk with the charge nurse and seek support from peers on the unit. Explanation: Talking with the charge nurse and the nurse's own peers provides an opportunity for the nurse to express legitimate feelings and receive support and encouragement from others who understand. Although requesting vacation time may be helpful for the nurse in the short term, it isn't the best step to take. Requesting a less-demanding assignment is avoidant and doesn't address the nurse's feelings. Continuing to work without dealing with the feelings doesn't allow the nurse to provide the most therapeutic care to the clients. One of the most important factors in psychiatric nursing is self-knowledge.

When a client diagnosed with paranoid schizophrenia tells the nurse, "I have to get away. The volmers are coming to execute me," an appropriate response for the nurse would be A. "You are safe here. This is a locked unit, and no one can get in." B. "I do not believe I understand the word volmers. Tell me more about them." C. "Why do you think someone or something is going to harm you?" D. "It must be frightening to think something is going to harm you."

D This response focuses on the client's feelings and neither directly supports the delusion nor denies the client's experience. Option A gives global reassurance. Option B encourages elaboration about the delusion. Option C asks for information that the client will likely be unable to answer.

The nurse is assessing a pt dx with disorganized schizophrenia. Which symptoms should the nurse expect he client to exhibit? A. markedly regressive, primitive behavior, and extremely poor contact with reality. Affect is flat or grossly inappropriate. Personal appearance is neglected and social impairment is extreme. B. Marked abnormalities in motor behavior manifested in extreme psychomotor retardation with pronounced decreases in spontaneous movements and activity. Waxy flexibility is exhibited. C. Exhibiting delusions of persecution or grandeur. Auditory hallucinations related to a persecutory theme are present. Tense, suspicious and guarded and may be argumentative, hostile, and aggressive. D. Has a hx of active psychotic symptoms, such as delusions or auditory and visual hallucinations, but these prominent psychotic symptoms are not exhibited currently.

A A: This option accurately describes the symptoms associated with disorganized schizophrenia. The emphasis on regressive and primitive behavior, poor contact with reality, flat or inappropriate affect, neglected personal appearance, and extreme social impairment aligns with the characteristics of this subtype of schizophrenia. B: This description is more indicative of catatonic schizophrenia rather than disorganized schizophrenia. Catatonic schizophrenia is characterized by disturbances in motor behavior, including psychomotor retardation and waxy flexibility. C: This option describes symptoms commonly associated with paranoid schizophrenia, such as delusions of persecution or grandeur, auditory hallucinations, tension, suspicion, and guarded behavior. These features are not typically characteristic of disorganized schizophrenia.

The nurse assesses a pt that tells her "we wanted to take the bus, but the airport took all the traffic." The nurse will chart this as the client is experiencing what? A. associative looseness B. communication by use of word salad C. delusional thinking D. an illusion involving planes

A associative looseness is thinking characterized by speech shifting ideas from one unrelated subject to another. Pt is unaware they are unconnected.

Which time periods during antidepressant therapy are persons most likely to commitsuicide? Select all that apply. A) After starting antidepressant therapy but not having reached the therapeutic level B) After having reached the therapeutic level of antidepressants and maintained it forseveral years C) If the client has made a choice to discontinue antidepressant therapy withoutmedical supervision and is becoming gradually more depressed D) If the client does not adhere to the medication regimen and takes antidepressantmedications irregularly E) Prior to initiating antidepressant therapy but before the depression results in lackof energy

A, C, D, E

Which nursing intervention strategy is most appropriate to implement initially with a suicidal client? A. Ask a direct question such as, Do you ever think about killing yourself? B. Ask client, Please rate your mood on a scale from 1 to 10. C. Establish a trusting nurseclient relationship. D. Apply the nursing process to the planning of client care.

ANS: A The risk of suicide is greatly increased if the client has suicidal ideations, if the client has developed a plan, and particularly if the means exist for the client to execute the plan.

An isolative client was admitted 4 days ago with a diagnosis of major depressive disorder. Which nursing statement would best motivate this client to attend a therapeutic group being held in the milieu? A. "We'll go to the day room when you are ready for group." B. "I'll walk with you to the day room. Group is about to start." C. "It must be difficult for you to attend group when you feel so bad." D. "Let me tell you about the benefits of attending this group."

ANS: B A client diagnosed with major depressive disorder exhibits little to no motivation and must be firmly directed by staff to participate in therapy. It is difficult for a severely depressed client to make decisions, and this function must be temporarily assumed by the staff.

A nurse is implementing a one-on-one suicide observation level with a client diagnosed with major depressive disorder. The client states, "I'm feeling a lot better so you can stop watching me. I have taken up too much of your time already." Which is the best nursing reply? A. "I really appreciate your concern but I have been ordered to continue to watch you." B. "Because we are concerned about your safety, we will continue to observe you." C. "I am glad you are feeling better. The treatment team will consider your request." D. "I will forward you request to your psychiatrist because it is his decision."

ANS: B Often suicidal clients resist personal monitoring which impedes the implementation of a suicide plan. A nurse should continually observe a client when risk for suicide is suspected.

During an admission assessment, a nurse asks a client diagnosed with schizophrenia, Have you ever felt that certain objects or persons have control over your behavior? The nurse is assessing for which type of thought disruption? A. Delusions of persecution B. Delusions of influence C. Delusions of reference D. Delusions of grandeur

ANS: B The nurse is assessing the client for delusions of influence when asking if the client has ever felt that objects or persons have control of the clients behavior. Delusions of control or influence are manifested when the client believes that his or her behavior is being influenced. An example would be if a client believes that a hearing aid receives transmissions that control personal thoughts and behaviors.

What is the rationale for a nurse to perform a full physical health assessment on a client admitted with a diagnosis of major depressive disorder? A. The attention during the assessment is beneficial in decreasing social isolation. B. Depression can generate somatic symptoms that can mask actual physical disorders. C. Physical health complications are likely to arise from antidepressant therapy. D. Depressed clients avoid addressing physical health and ignore medical problems.

ANS: B The nurse should determine that a client with a diagnosis of major depressive disorder needs a full physical health assessment because depression can generate somatic symptoms that can mask actual physical disorders. Somatization is the process by which psychological needs are expressed in the form of physical symptoms.

A client has been recently admitted to an inpatient psychiatric unit. Which intervention should the nurse plan to use to reduce the clients focus on delusional thinking? A. Present evidence that supports the reality of the situation B. Focus on feelings suggested by the delusion C. Address the delusion with logical explanations D. Explore reasons why the client has the delusion

ANS: B The nurse should focus on the clients feelings rather than attempt to change the clients delusional thinking by the use of evidence or logical explanations. Delusional thinking is usually fixed, and clients will continue to have the belief in spite of obvious proof that the belief is false or irrational.

A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this clients safety? A. Assess for medication noncompliance B. Note escalating behaviors and intervene immediately C. Interpret attempts at communication D. Assess triggers for bizarre, inappropriate behaviors

ANS: B The nurse should note escalating behaviors and intervene immediately to maintain this clients safety.

A college student has quit attending classes, isolates self because of hearing voices, and yells accusations at fellow students. Based on this information, which nursing diagnosis should the nurse prioritize? A. Altered thought processes R/T hearing voices AEB increased anxiety B. Risk for other-directed violence R/T yelling accusations C. Social isolation R/T paranoia AEB absence from classes D. Risk for self-directed violence R/T depressed mood

ANS: B The nursing diagnosis that must be prioritized in this situation is risk for other-directed violence R/T yelling accusations. Hearing voices and yelling accusations indicate a potential for violence, and this potential safety issue should be prioritized. The priority nursing diagnosis is "risk for other-directed violence R/T yelling accusations." Safety is always the priority. Verbal aggression is a behavior indicating risk for violence. Other risk factors include aggressive body language, command hallucinations, rage reactions, and destruction of objects in the environment. Social isolation and paranoia do not take priority over the risk for other-directed violence.

After years of dialysis, an 84-year-old states, Im exhausted, depressed, and done with these attempts to keep me alive. Which question should the nurse ask the spouse when preparing a discharge plan of care? A. Have there been any changes in appetite or sleep? B. How often is your spouse left alone? C. Has your spouse been following a diet and exercise program consistently? D. How would you characterize your relationship with your spouse?

ANS: B This client has many risk factors for suicide. The client should have increased supervision to decrease likelihood of self-harm.

A client diagnosed with schizophrenia tells a nurse, The Shopatouliens took my shoes out of my room last night. Which is an appropriate charting entry to describe this clients statement? A. The client is experiencing command hallucinations. B. The client is expressing a neologism. C. The client is experiencing a paranoia. D. The client is verbalizing a word salad.

ANS: BThe nurse should describe the clients statement as experiencing a neologism. A neologism is when a client invents a new word that is meaningless to others but may have symbolic meaning to the client. Word salad refers to a group of words that are put together randomly. C The client's use of the word "Shopatouliens" is an example of a neologism, a newly invented word that is meaningless to others but has symbolic meaning to the individual. Paranoid thinking is characterized by extreme suspiciousness of others and their actions or perceived intentions

Which client data indicate that a suicidal client is participating in a plan for safety? A. Compliance with antidepressant therapy B. A mood rating of 9/10 C. Disclosing a plan for suicide to staff D. Expressing feelings of hopelessness to nurse

ANS: C A degree of the responsibility for the suicidal clients safety is given to the client. When a client shares with staff a plan for suicide, the client is participating in a plan for safety by communicating thoughts of self-harm that would initiate interventions to prevent suicide.

A client states, "I hear voices that tell me that I am evil." Which outcome related to these symptoms should the nurse expect this client to accomplish by discharge? A. The client will verbalize the reason the voices make derogatory statements. B. The client will not hear auditory hallucinations. C. The client will identify events that increase anxiety and illicit hallucinations. D. The client will positively integrate the voices into the client's personality structure.

ANS: C It is unrealistic to expect the client to completely stop hearing voices. Even when compliant with antipsychotic medications, clients may still hear voices. It would be realistic to expect the client to associate stressful events with an increase in auditory hallucinations. By this recognition the client can anticipate symptoms and initiate appropriate coping skills. It can be challenging to predict whether a client will completely stop hearing voices, as it depends on various factors. The goal of treatment is often to manage and alleviate symptoms, improve overall functioning, and enhance the individual's quality of life. This may involve helping the individual develop coping strategies, addressing underlying issues contributing to the hallucinations, and providing ongoing support.

A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol), 50 mg bid; benztropine (Cogentin), 1 mg prn; and zolpidem (Ambien), 10 mg HS. Which client behavior would warrant the nurse to administer benztropine? A. Tactile hallucinations B. Tardive dyskinesia C. Restlessness and muscle rigidity D. Reports of hearing disturbing voices

ANS: C The symptom of tactile hallucinations and reports of hearing disturbing voices would be addressed by an antipsychotic medication such as haloperidol. Tardive dyskinesia, a potentially irreversible condition, would warrant the discontinuation of an antipsychotic medication such as haloperidol. An anticholinergic medication such as benztropine would be used to treat the extrapyramidal symptoms of restlessness and muscle rigidity.

A nurse is assessing a client diagnosed with schizophrenia. The nurse asks the client, Do you receive special messages from certain sources, such as the television or radio? Which potential symptom of this disorder is the nurse assessing? A. Thought insertion B. Paranoia C. Magical thinking D. Delusions of reference

ANS: D The nurse is assessing for the potential symptom of delusions of reference. A client who believes that he or she receives messages through the radio is experiencing delusions of reference. When a client experiences these delusions, he or she interprets all events within the environment as personal references. Grandiose delusions are characterized by the client's claim to association with famous people or celebrities, or the client's belief that he or she is famous or capable of great feats. Examples: The client may claim to be engaged to a famous movie star or related to some public figure, such as claiming to be the daughter of the president of the United States, or he or she may claim to have found a cure for cancer. = 허언증 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. Examples: The client may report that the president was speaking directly to h

A nurse assesses a client suspected of having major depressive disorder. Which client symptom would eliminate this diagnosis? A. The client is disheveled and malodorous. B. The client refuses to interact with others. C. The client is unable to feel any pleasure. D. The client has maxed-out charge cards and exhibits promiscuous behaviors.

ANS: D The nurse should assess that a client who has maxed-out credit cards and exhibits promiscuous behavior would be exhibiting manic symptoms. According to the DSM-IV-TR, these symptoms would rule out the diagnosis of major depressive disorder.

A client diagnosed with schizophrenia, who has been taking antipsychotic medication for the last 5 months, presents in an emergency department (ED) with uncontrollable tongue movements, stiff neck, and difficulty swallowing. The nurse would expect the physician to recognize which condition and implement which treatment? A. Neuroleptic malignant syndrome, treated by discontinuing antipsychotic medications B. Agranulocytosis, treated by administration of clozapine (Clozaril) C. Extrapyramidal sym

ANS: D The nurse should expect that an ED physician would diagnose the client with tardive dyskinesia and discontinue antipsychotic medications. Tardive dyskinesia is a condition of abnormal involuntary movements of the mouth, tongue, trunk, and extremities that can be an irreversible side effect of typical antipsychotic medications.

A nurse is assessing a client with chronic schizophrenia. Which effects will the client most likely exhibit? Select all that apply. Apathy Sadness Flatness Hostility Happiness Depression

Apathy Flatness Apathy (indifference) is common among people with chronic schizophrenia because negative symptoms are more apparent. Flatness, with few extremes of emotion, is common among people with chronic schizophrenia because negative symptoms are more apparent. Extremes in emotions are not associated with chronic schizophrenia. Sadness is related more to mood disorders, such as a depressive episode of bipolar disorder or major depression. Hostility may be seen in some forms of schizophrenia, such as paranoid schizophrenia, but it is rarely seen in the chronic stages. Happiness and elation are associated with manic episodes of bipolar disorder, not chronic schizophrenia. Depression is related to mood disorders, such as a depressive episode of bipolar disorder or major depression.

16. Which is a correctly written, appropriate outcome for a client with a history of suicide attempts who is currently exhibiting symptoms of low self-esteem by isolating self? A. The client will not physically harm self. B. The client will express three positive self-attributes by day 4. C. The client will reveal a suicide plan. D. The client will establish a trusting relationship.

B Although the client has a history of suicide attempts, the current problem is isolative behaviors based on low self-esteem. Outcomes should be client centered, specific, realistic, and measureable and contain a time frame.

Which variables represent the highest risk for developing major depressive disorder?Select all that apply. A) Male gender B) Mood disorder in first-degree relatives C) Substance abuse D) Divorced E) Older adult

B, D

A client with a chronic mental illness has worked as a hotel maid for the past 3 years. She tells the nurse she is thinking of quitting her job because "voices on television are talking about me." The nurse should first: a) check with the client's employer about her work performance. b) remind the client that hearing voices is a symptom of her illness with which she can cope. c) obtain information about the client's medication compliance. d) arrange for the client to be admitted to a psychiatric hospital for a short stay.

C

The wife of a client admitted for treatment of newly diagnosed paranoid schizophrenia visits 2 days after her husband's admission and states to the nurse, "Why is he not eating? He is still talking about his food being poisoned." Which appraisal by the nurse is most accurate? a) Her expectations of her husband are realistic. b) The wife's inquiry is reasonable. c) Education about her husband's medications is needed. d) An increase in the client's medication is indicated.

C

The nurse is planning care for a client with major depression. Which is an appropriateexpected outcome? A) The client will avoid causing harm to others. B) The client will be free from stress. C) The client will independently carry out activities of daily living. D) The client will not experience agitation.

C Major depression can significantly impact a person's ability to perform daily activities. By setting a goal for the client to independently carry out activities of daily living, the nurse is addressing the functional impairment often associated with depression. This outcome focuses on improving the client's overall functioning and independence, which is an important aspect of their well-being. Options A, B, and D address specific aspects of the client's behavior or emotional state but may not be as directly related to the improvement of daily functioning that is often a key goal in the care of individuals with major depression.

Pt dx with schizophrenia is experiencing anhedonia. Which dx addresses this correctly? A. disturbed thought process B. disturbed sensory perception C. risk for suicide D. impaired verbal communication

C negative symptoms of anhedonia (inability to experience pleasure) generates hopelessness and can lead to thoughts of suicide.

The nurse is going over the side effects of the schizophrenia pts antipsychotic med when the pt says "I have not had a period in 5 months and it is great." Which teaching intervention should be in the nurses POC? A. antipsychotic meds can cause low libido B. antipsychotic meds can decrease RBCs, leading to amenorrhea C. antipsychotic meds can cause amenorrhea, but ovulation still occurs D. antipsychotic meds can interfere with the effectiveness of birth control

C they do cause amenorrhea but ovulation still takes place. It is important that the pt know the potential for pregnancy. This teaching is VITAL in the planthe med does cause decreased libido but that's not the pts problem here.no evidence that the med interferes w/BC or that it decreases RBCs

A client has just been diagnosed as having major depression. At which time would thenurse expect the client to be at highest risk for self-harm? A) Immediately after a family visit B) On the anniversary of significant life events in the client's life C) During the first few days after admission D) Approximately 2 weeks after starting antidepressant medication

D Observe the client closely for suicide potential, especially after antidepressant medication begins to raise the client's mood. Risk for suicide increases as the client's energy level is increased by medication. The other choices are not significantly associated with increased risk for suicide.

Which nursing intervention would be most appropriate when caring for an acutely agitated client with paranoia? A. Provide neon lights and soft music. B. Maintain continual eye contact throughout the interview. C. Use therapeutic touch to increase trust and rapport. D. Provide personal space to respect the clients boundaries.

D Safety for both the client and the nurse is the priority when providing care for the client with schizophrenia. The client may be paranoid and suspicious of the nurse and the environment and may feel threatened and intimidated. Although the client's behavior may be threatening to the nurse, the client is also feeling unsafe and may believe his or her well-being is in jeopardy. Therefore, the nurse must approach the client in a nonthreatening manner. Making demands or being authoritative only increases the client's fears. Giving the client ample personal space usually enhances his or her sense of security.

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

D. attending day therapy three times a week Attending day therapy three times per week is a long-term goal that will show the most progress in overcoming withdrawal. The client's calling his mother is a first step in getting out of a severe withdrawal. Allowing two friends to visit every day would be appropriate if the client is successful with calling his mother once a day. Insufficient information is presented in the scenario to indicate that excessive sleep is a problem.

A client with the diagnosis of schizophrenia refuses to eat meals. Which nursing action is most beneficial for this client? Directing the client repeatedly to eat the food Explaining to the client the importance of eating Waiting and allowing the client to eat whenever the client is ready Having a staff member sit with the client in a quiet area during mealtimes

Having a staff member sit with the client in a quiet area during mealtimes By sitting with the client during mealtimes the nurse can evaluate how much the client is eating; this encourages the client to eat and begins the construction of a trusting relationship. Fewer distractions may help the client focus on eating. The client will not follow directions to eat because of the nature of the illness. Explaining the importance of eating and allowing the client to eat when ready are both unrealistic and will not ensure adequate intake.

What should the nurse do when a client with the diagnosis of schizophrenia talks about being controlled by others? Express disbelief about the client's delusion. Divert the client's attention to unit activities. React to the feeling tone of the client's delusion. Respond to the verbal content of the client's delusion

React to the feeling tone of the client's delusion. Reacting to the feeling tone of the client's delusion helps the client explore underlying feelings and allows the client to see the message that his verbalizations are communicating. Expressing disbelief about the client's delusion denies the client's feelings rather than accepting and working with them. Attempting to divert the client rather than accepting and working with him denies the client's feelings. Responding to the verbal content of the client's delusion focuses on the delusion itself rather than on the feeling that is causing the delusion.

By identifying behaviors commonly exhibited by the client who has a diagnosis of schizophrenia, the nurse can anticipate: Disorientation, forgetfulness, and anxiety Grandiosity, arrogance, and distractibility Withdrawal, regressed behavior, and lack of social skills Slumped posture, pessimistic outlook, and flight of ideas

Withdrawal, regressed behavior, and lack of social skills Withdrawal, regressed behavior, and lack of social skills are classic behaviors exhibited by clients with a diagnosis of schizophrenia. Disorientation, forgetfulness, and anxiety are more commonly associated with dementia. Grandiosity, arrogance, and distractibility are more commonly associated with bipolar disorder, manic phase. Slumped posture, pessimistic outlook, and flight of ideas are more commonly associated with depression.