354 Exam2

A hyperactive self-destructive child is to be discharged from an inpatient setting in a few days. In preparation for the child's discharge, it is most important for the nurse to plan to: A. Establish, maintain, and enforce limits on behavior B. Meet with the child's teacher to review the child's needs C. Schedule a team conference with the child and the parents D. Help the child begin to terminate relationships with the nursing team

C. Schedule a team conference with the child and the parents

A nurse is assessing an adolescent client with the diagnosis of schizophrenia, undifferentiated type. Which signs and symptoms should the nurse expect the client to experience? A. Paranoid delusions and hypervigilance B. Depression and psychomotor retardation C. Loosened associations and hallucinations D. Ritualistic behaviors and obsessive thinking

C. Loosened associations and hallucinations

The nurse is preparing a client with a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client understands the instructions? A. "My medications aren't likely to make me anxious." B. "I'll go to support group and talk so that I don't hurt anyone." C. "It's not likely that I'll get anxious or hear things if I get enough sleep and eat well." D. "When I begin to hallucinate, I'll call my therapist and talk about what I should do."

D. "When I begin to hallucinate, I'll call my therapist and talk about what I should do."

Frontal lobe deficits in schizophrenia are thought to be responsible for: A. Disorganized thinking B. Hallucinations C. Depression D. Parkinsonism

A. Disorganized thinking

The nurse manager is evaluating a primary nurse who is working with a hospitalized adolescent client with the diagnosis of conduct disorder. Which intervention by the primary nurse should the nurse manger question? 1. Discussing rules of the unit 2. Allows opportunities for choices 3. Explaining the consequences for not following unit regulations 4. Encouraging the verbalization of negative feelings toward others

1. Discussing rules of the unit

Which neurological deficits would the nurse be most likely to encounter when assessing a patient diagnosed with schizophrenia? A. Weakness and loss of function B. Paralysis and diminished reflexes C. Droopy eyelids and reddened cornea D. Increased blinking and impaired fine motor skills

D. Increased blinking and impaired fine motor skills

To help a disturbed, acting-out child develop a trusting relationship, the nurse should: A. Inquire as to the child's feelings about the parents B. Implement a half hour one-to-one interaction daily C. Initiate limit setting and explain the rules to be followed D. Offer periodic support and emphasize safety in play activities

D. Offer periodic support and emphasize safety in play activities

The medical record of a patient diagnosed with schizophrenia states that the patient has cognitive dysfunction. From this statement, the nurse can expect to see evidence of: A. anxiety, fear, and agitation. B. aggression, anger, hostility, or violence. C. blunted or flat affect or inappropriate affective responses. D. impaired memory and attention as well as formal thought disorder.

D: impaired memory and attention as well as formal thought disorder.

A nurse teaches a client about the side effects and precautions associated with the typical antipsychotic haloperidol (Haldol). The nurse evaluates that the teaching is understood when the client states: 1. "I will immediately report any diarrhea or vomiting to my doctor." 2. "I will not eat any tyramine-containing foods while I'm taking this drug." 3. "I'll avoid direct sunlight and use a sunscreen product when I go outdoors." 4. "I'll maintain an adequate fluid intake because I may urinate more than usual."

3. "I'll avoid direct sunlight and use a sunscreen product when I go outdoors."

The nurse finds a client with schizophrenia lying under a bench in the hall. The client states, "God told me to lie here." What is the best response by the nurse? A. "I didn't hear anyone talking. Come with me to your room." B. "What you heard was in your head; it was your imagination." C. "Come to the dayroom and watch television. You will feel better." D. "God would not tell you to lie in the hall. God wants you to behave reasonably."

A. "I didn't hear anyone talking. Come with me to your room."

A client who has been admitted with a diagnosis of schizophrenia says to the nurse, "Yes, it's March. March is Little Women. That's literal you know." These statements illustrate: A. Loose associations B. Word salad C. Flight of ideas D. Echolalia

A. Loose associations

When caring for a withdrawn, reclusive, psychotic client, the priority goal is for the client to develop: A. Trust B. Self-worth C. A sense of identity D. An ability to socialize

A. Trust

A patient chart reports he is displaying positive symptoms of schizophrenia. The nurse can expect the patient to show evidence of: A. delusions and hallucinations. B. grimacing and mannerisms. C. echopraxia and echolalia. D. avolition and anhedonia.

A. delusions and hallucinations.

The nursing diagnosis most likely to be applicable for a person who has schizophrenia, paranoid type, is: A. social isolation related to impaired ability to trust. B. impaired mobility related to fear of losing control of hostile impulses. C. fear of being alone related to lack of confidence in significant others. D. impaired memory related to poor information processing associated with brain deficits.

A: social isolation related to impaired ability to trust.

When assessing the mental status of a 7- or 8-year-old child, it is most important for the nurse to: A. Listen to the parent's description of the child's behavior B. Compare the child's functioning from one day to another C. Engage parents in a discussion about the child's feelings D. Determine the child's mental status by using direct questions

B. Compare the child's functioning from one day to another

A young adult client is admitted to the hospital with a diagnosis of schizophrenia, paranoid type. The client has been saying, "The voices in heaven are telling me to come home to God." Initial nursing care should focus on the client's: A. Disturbed self-esteem B. Potential for self-harm C. Dysfunctional verbal communication D. Impaired perception of environmental stimuli

B. Potential for self-harm

The nurse notes that a client with schizophrenia and receiving an antipsychotic medication is moving her mouth, protruding her tongue, and grimacing as she watches television. The nurse determines that the client is experiencing which medication complication? A. Parkinsonism B. Tardive Dyskinesia C. Hypertensive crisis D. Neuroleptic Malignant Syndrome

B. Tardive Dyskinesia

A client says to the nurse, "The federal guards were sent to kill me." What is the best nursing response to the client's concern? A. "I don't believe this is true." B. "The guards are not out to kill you" C. "Do you feel afraid that people are trying to hurt you?" D. "What makes you think the guards were sent out to hurt you?

C. "Do you feel afraid that people are trying to hurt you?"

A child with ADHD had this nursing diagnosis: impaired social interaction, related to excessive neuronal activity, as evidenced by aggressiveness and dysfunctional play with others. Which finding indicates the plan of care was effective? A. Improved ability to identify anxiety and use self-control strategies B. Increased expressiveness in communication with others C. Engages in cooperative play with other children D. Increased responsiveness to authority figures

C. Engages in cooperative play with other children

The nurse is caring for a client who is experiencing disturbed thought processes as a result of paranoia. In formulating nursing interventions with the members of the health care team, what best instruction should the nurse provide to the staff? A. Have the client sign a release of information to appropriate parties for assessment purposes. B. Increase socialization of the client with peers. C. Begin to educate the client about social supports in the community. D. Avoid laughing or whispering in front of the client.

D. Avoid laughing or whispering in front of the client.

A client with schizophrenia has been started on medication therapy with clozapine (Clozaril). The nurse should assess the results of which laboratory study to monitor for adverse effects from this medication? A. Platelet Count B. Blood Glucose C. Liver Function Tests D. White Blood Cell Count

D. White Blood Cell Count - agranulocytosis

What part of the brain is dysfunctional in persons with schizophrenia? Research has implicated the: A. medulla and cortex. B. cerebellum and cerebrum. C. hypothalamus and medulla. D. prefrontal and limbic cortices

D. prefrontal and limbic cortices