mental health test 2 part 3
A withdrawn client, newly diagnosed with Schizophrenia, is experiencing delusional thinking. Which nursing intervention is most appropriate? A. Present objective reality B. Use self-disclosure C. Use physical touch for reassurance D. Explain in depth, unit rules and regulations
ANS: A
A client diagnosed with Schizophrenia experiences identity confusion and communicates with the nurse using echolalia. What is the client attempting to do by using this form of speech? A. Identify with the person speaking B. Imitate the nurses movements C. Alleviate alogia D. Alleviate avolition
ANS: A Echolalia is a parrot-like repetition of overheard words or fragments of speech. It is an attempt to identify with the person speaking.
An individual with a history of antisocial personality disorder was arrested for driving under the influence of alcohol and causing a serious car accident. Which comment on this behavior would be expected? a. It's not my fault. b. I'm too ashamed to talk about it. c. I just don't remember doing it. d. I'm really sorry about all the people I've hurt.
ANS: A Individuals diagnosed with antisocial personality disorders lack remorse about their actions and view themselves as victims. This individual would most likely refuse to acknowledge responsibility for the accident.
A client diagnosed with antisocial personality disorder is admitted to the inpatient unit after setting the police chief's house on fire. The client is scheduled for further psychological testing this morning. Which nursing intervention takes priority? a. Instruct the client about psychological testing b. Explore alternatives to pyromania c. Limit the client's social interactions d. Encourage the client to follow the unit rules
ANS: A It is appropriate prior to any testing for the nurse to explain the procedure and what the client should expect. This information will put the client at ease and may lead to client cooperation and more accurate testing results. Because the psychological testing will be administered in the morning, this nursing intervention takes priority.
A client tells the nurse, You're so much nicer than that mean nurse on nightshift. This statement would be associated with which personality disorder? a. Borderline b. Histrionic c. Schizoid d. Avoidant
ANS: A This statement would be typical of a client dediagnosed with borderline personality disorder. These clients typically generate conflict in a maladaptive attempt to gain attention and acceptance. They use splitting, which is an ego defense manifested by an inability to integrate and accept both positive and negative feelings. Individuals, including themselves, are viewed as either all good or all bad.
A client, diagnosed with Paranoid Schizophrenia, states, "My roommate is plotting to have others kill me." Which is the appropriate nursing response? A. "I find it hard to believe." B. "What would make you thin such a thing?" C. "I know your roommate. He would do no such thing." D. "I can see why you feel that way."
ANS: A voicing doubt; used for delusions
If clozapine (Clozaril) therapy is being considered, the nurse should evaluate which laboratory test to establish a baseline for comparison in order to recognize a potentially life-threatening side effect? A. White blood cell count B. Liver function studies C. Creatinine clearance D. Blood urea nitrogen
ANS: A The nurse should establish a baseline white blood cell count to evaluate a potentially life-threatening side effect if clozapine (Clozaril) is being considering as a treatment option. Clozapine can have a serious side effect of agranulocytosis in which a potentially fatal drop in white blood cells can occur.
After taking chlorpromazine (Thorazine) for 1 month, a client presents to an emergency department (ED) with severe muscle rigidity, tachycardia, and a temperature of 105oF (40.5C). The nurse expects the physician to recognize which condition and implement which treatment? A. Neuroleptic malignant syndrome and treat by discontinuing Thorazine and administering dantrolene (Dantrium) B. Neuroleptic malignant syndrome and treat by increasing Thorazine dosage and administering an antianxiety medication C. Dystonia and treat by administering trihexyphenidyl (Artane) D. Dystonia and treat by administering bromocriptine (Parlodel)
ANS: A The nurse should expect that an ED physician would diagnose the client with neuroleptic malignant syndrome and treat the client by discontinuing chlorpromazine (Thorazine) and administering dantrolene (Dantrium). Neuroleptic malignant syndrome is a potentially fatal condition characterized by muscle rigidity, fever, altered consciousness, and autonomic instability. The use of typical antipsychotics is largely being replaced by atypical antipsychotics due to fewer side effects and lower risks.
A 16-year-old-client diagnosed with paranoid schizophrenia experiences command hallucinations to harm others. The client's parents ask a nurse, "Where do the voices come from?" Which is the appropriate nursing reply? A. "Your child has a chemical imbalance of the brain which leads to altered thoughts." B. "Your child's hallucinations are caused by medication interactions." C. "Your child has too little serotonin in the brain causing delusions and hallucinations." D. "Your child's abnormal hormonal changes have precipitated auditory hallucinations."
ANS: A The nurse should explain that a chemical imbalance of the brain leads to altered thought processes. Hallucinations, or false sensory perceptions, may occur in all five senses. The client who hears voices is experiencing an auditory hallucination.
A client diagnosed with schizophrenia is prescribed clozapine (Clozaril). Which client symptoms related to the side effects of this medication should prompt a nurse to intervene immediately? A. Sore throat, fever, and malaise B. Akathisia and hypersalivation C. Akinesia and insomnia D. Dry mouth and urinary retention
ANS: A The nurse should intervene immediately if the client experiences a sore throat, fever, and malaise when taking the atypical antipsychotic drug clozapine (Clozaril). Clozapine can have a serious side effect of agranulocytosis, in which a potentially fatal drop in white blood cells can occur. Symptoms of infectious processes would alert the nurse to this potential.
Which statement should indicate to a nurse that an individual is experiencing a delusion? A. "There's an alien growing in my liver." B. "I see my dead husband everywhere I go." C. "The IRS may audit my taxes." D. "I'm not going to eat my food. It smells like brimstone."
ANS: A The nurse should recognize that a client who claims that an alien is inside his or her body is experiencing a delusion. Delusions are false personal beliefs that are inconsistent with the person's intelligence or cultural background.
Laboratory results reveal decreased levels of prolactin in a client diagnosed with schizophrenia. When assessing the client, which symptoms should a nurse expect to observe?(Select all that apply.) A. Apathy B. Social withdrawal C. Anhedonia D. Auditory hallucinations E. Delusions
ANS: A, B, C The nurse should expect that a client with decreased levels of prolactin would experience apathy, social withdrawal, and anhedonia. Decreased levels of prolactin can cause depression which would result in the above symptoms.
A client, experiencing command hallucinations, is hospitalized after jumping from a bridge. The client's parents insist their son fell rather than jumped. Which of the following best explains the parents' response? Select all that apply: A. The parents are in denial about the reality of their son's mental illness B. The parents are grieving over the loss of their expectations for their child C. The parents do not understand the extent or seriousness of mental illness D. The parents reject the idea of their son having a mental illness E. The parents are showing support for their son
ANS: A, B, C, & D
Which of the following components should a nurse recognize as an integral part of a rehabilitative program when planning care for clients diagnosed with schizophrenia? (Select all that apply.) A. Group therapy B. Medication management C. Deterrent therapy D. Supportive family therapy E. Social skills training
ANS: A, B, D, E The nurse should recognize that group therapy, medication management, supportive family therapy, and social skills training all play an integral part in rehabilitative programs for clients diagnosed with schizophrenia. Schizophrenia results from various combinations of genetic predispositions, biochemical dysfunctions, physiological factors, and psychological stress. Effective treatment requires a comprehensive, multidisciplinary effort.
A nurse is admitting a client with a new diagnosis of a personality disorder. Which of the following would make the nurse question this diagnosis? (Select all that apply.) A. The client has been diagnosed with sickle cell anemia. B. The client has an inflated self-appraisal and feels a sense of entitlement. C. The client has a history of a substance use disorder. D. The client is odd and eccentric but not delusional. E. The client has an intellectual developmental disorder.
ANS: A, C, & E The DSM-5 states that impairments in personality functioning and the individual's personality trait expression are not better understood as normative for the individual's developmental stage or sociocultural environment. The impairments in personality functioning and the individual's personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma). The nurse would question the diagnosis of a personality disorder in a client with sickle cell anemia, substance use disorder, or an intellectual developmental disorder.
A nurse is administering risperidone (Risperdal) to a client diagnosed with schizophrenia. The therapeutic effect of this medication would most effectively address which of the following symptoms? (Select all that apply.) A. Somatic delusions B. Social isolation C. Gustatory hallucinations D. Flat affect E. Clang associations
ANS: A, C, E The nurse should expect that risperidone (Risperdal) would be effective treatment for somatic delusions, gustatory hallucinations, and clang associations. Risperidone is an atypical antipsychotic that has been effective in the treatment of the positive symptoms of schizophrenia and in maintenance therapy to prevent exacerbation of schizophrenic symptoms.
A financially secure client, diagnosed with Schizophrenia, angerly states, "I've been taking Risperdal for 5 years. I can't afford the medication so I'm not taking it anymore." Which defense mechanism is this client using? A. Regression B. Rationalization C. Sublimation D. Projection
ANS: B
When assessing a client diagnosed with narcissistic personality disorder, the nurse expects to identify which characteristic behavior? a. Odd beliefs and magical thinking b. Grandiose sense of self importance c. Pattern of intense and chaotic relationships d. Submissive and clinging behaviors
ANS: B Clients diagnosed with narcissistic personality disorder have an exaggerated sense of self-worth. They are often grandiose and believe they have an inalienable right to receive special consideration.
A nursing student is learning about schizoid personality disorder. Which statement by the student indicates that learning has occurred? a. These individuals have peculiarities of ideation b. These individuals have a profound inability to form personal relationships. c. These individuals have an excessive need to be taken care of by others. d. These individuals have an unrealistic sense of entitlement.
ANS: B Having a profound inability to form personal relationships is characteristic of clients diagnosed with schizoid personality disorder. These individuals display a lifelong pattern of social withdrawal, and their discomfort with human interaction is apparent.
A 30-year-old continually changes jobs and has difficulty establishing long-term relationships. According to Erikson's psychosocial theory, this client is having difficulty successfully completing which development task conflict? a. Industry versus inferiority b. Intimacy versus isolation c. Generativity versus stagnation d. Ego integrity versus despair
ANS: B Intimacy versus isolation takes place in early adulthood (ages 18 to 40). The goal of successful completion for this conflict is finding oneself, and cultivating/maintaining an effective loving relationship. This young man has moved from job to job, seeking his own identification, and has not yet been able to establish a meaningful long-term relationship. Therefore, he has not successfully completed this stage and is in the negative stage of Erikson's intimacy versus isolation psychosocial stage of personality development.
A mute client, diagnosed with Schizophrenia, displays Catatonia and waxy flexibility. Which nursing intervention would assist the client in communicating with others? A. Providing assistance with self-care B. Using clear, concrete statements C. Conveying acceptance of client's needs for false beliefs D. Attempting to decode incomprehensible communication patterns
ANS: B Shows the client what is expected. Because clients diagnosed with schizophrenia experience concrete thinking, explanations must be provided at the client's concrete level of comprehension.
A nursing home resident taking antipsychotic medications complains to the nurse of a stiff neck and difficulty swallowing. These symptoms are indicative of which condition? A. Dysphonia B. Tardive dyskinesia C. Akathisia D. Echolalia
ANS: B Tardive dyskinesia is involuntary movement of the tongue, stiff neck, and difficulty in swallowing.
In planning care to reinforce reality with a client diagnosed with Schizophrenia, which nursing intervention should be included? A. Explore the client's expressions of distorted thinking. B. Discuss perceptions and thinking that are in touch with reality C. Encourage client to share delusional thinking in group D. Ask client why distorted thinking and bizarre behavior have occurred
ANS: B The plan should focus on reinforcing perceptions and thinking that is in touch with reality.
Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia? A. Establishing personal contact with family members. B. Being reliable, honest, and consistent during interactions. C. Sharing limited personal information. D. Sitting close to the client to establish rapport.
ANS: B The nurse can enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia by being reliable, honest, and consistent during interactions. The nurse should also convey acceptance of the client's needs and maintain a calm attitude when dealing with agitated behavior.
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 client's 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.
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 client's statement? A. "The client is experiencing command hallucinations." B. "The client is expressing a neologism." C. "The client is experiencing a paranoid delusion." D. "The client is verbalizing a word salad."
ANS: B The nurse should describe the client's 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.
A client has been recently admitted to an inpatient psychiatric unit. Which intervention should the nurse plan to use to reduce the client's 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 client's feelings rather than attempt to change the client's 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 client's 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 client's safety. Early intervention may prevent an aggressive response and keep the client and others safe.
A nurse is caring for a client who is experiencing a flat affect, paranoid delusions, anhedonia, anergia, neologisms, and echolalia. Which statement correctly differentiates the client's positive and negative symptoms of schizophrenia? A. Paranoid delusions, anhedonia, and anergia are positive symptoms of schizophrenia. B. Paranoid delusions, neologisms, and echolalia are positive symptoms of schizophrenia. C. Paranoid delusions, anergia, and echolalia are negative symptoms of schizophrenia. D. Paranoid delusions, flat affect, and anhedonia are negative symptoms of schizophrenia.
ANS: B The nurse should recognize that positive symptoms of schizophrenia include paranoid delusions, neologisms, and echolalia. The negative symptoms of schizophrenia include flat affect, anhedonia, and anergia. Positive symptoms reflect an excess or distortion of normal functions. Negative symptoms reflect a decrease or loss of normal functions.
A college student has quit attending classes, isolates self due to 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 should be risk for other-directed violence R/T yelling accusations. Hearing voices and yelling accusations indicates a potential for violence, and this potential safety issue should be prioritized.
The nurse is providing care for an emaciated client experiencing an acute phase of catatonic stupor. Which nursing intervention would take priority when meeting this client's needs? A. Provide speech therapy doe mutism B. Provide physical therapy for psychomotor retardation C. Provide nutrient-dense foods and beverages D. Provide a safe environment
ANS: C
In assessing a client diagnosed with borderline personality disorder, which characteristic would the nurse expect to observe? a. Predictability b. Controlled anger c. Little tolerance for being alone d. Stable and satisfactory relationships
ANS: C Clients diagnosed with borderline personality disorder have little tolerance for being along. They prefer a frantic search for companionship, no matter how unsatisfactory, rather than experiencing feelings of loneliness, emptiness, and boredom.
A client diagnosed with a personality disorder tells the nurse, With my expertise, I could become this hospital's CEO tomorrow. This statement would be associated with which personality disorder? a. Antisocial personality disorder b. Paranoid personality disorder c. Narcissistic personality disorder d. Passive-aggressive personality disorder
ANS: C Clients diagnosed with narcissistic personality disorder are often boastful and grandiose. These individuals have an exaggerated sense of self-worth. They believe that they have an inalienable right to receive special consideration and that their desire is sufficient justification for possessing whatever they seek.
A client is experiencing paranoid delusions and states, "The FBI and Phone Company are plotting against me." Which charting entry best describes this clients symptoms? A. "Experiencing grandiosity" B. "Experiencing erotomania" C. "Experiencing persecutory delusions" D. "Experiencing somatic delusions"
ANS: C Delusion of persecution is the feeling of being threatened and belief that others intend harm or persecution toward him or her. The client feels that the FBI and AT&T intend to harm or persecute her by plotting against her.
A client diagnosed with a borderline personality disorder presents to the mental health clinic and demands to see a counselor immediately. Which is the appropriate nursing action? a. Instruct the client to leave the clinic b. Confront demanding behaviors c. Explain the rules and set limits d. Help the client to come up with solutions to stressful situations.
ANS: C Explaining rules and setting limits establish clear boundaries. This provides the firm structure needed by a client diagnosed with borderline personality disorder. The nurse may state, Clients are seen in the order of their scheduled appointments. It looks like it will be another 20 minutes before you are seen.
A client who has been taking chlorpromazine (Thorazine) for several months presents in the emergency department with extrapyramidal symptoms (EPS) of restlessness, drooling, and tremors, What medication will the nurse expect the physician to order? A. Paroxetine (Paxil) B. Carbamazepine (Tegretol) C. Benztropine (Cogentin) D. Lorazepam (Ativan
ANS: C Get rid of extrapyramidal symptoms 1st, before they become permanent, then restlessness.
The client hears the word "match" the client replies, "A match. I like matches. They are light of the world. God will light the world. Let your light so shine." Which communication pattern does the nurse identify? A. Word salad B. Clang association C. Loose association D. Ideas or reference
ANS: C Loose association is characterized by communication in which ideas shift from one unrelated topic to another. The situation in the question clearly represents this communication pattern.
A client is admitted with a diagnosis of Schizoaffective Disorder. Which symptoms are characteristic of this diagnosis? A. Strong ego boundaries and abstract thinking B. Ataxia and Akinesia C. Altered mood and thought disturbances D. Substance abuse and cachexia
ANS: C Schizoaffective disorder is manifested by schizophrenic behaviors, along with symptoms of mood disorders, either manic or depression. Therefore, assessing the client's mood and thought processes is paramount.
A mute client has been admitted to the inpatient psychiatric unit with a diagnosis of Catatonic Schizophrenia. What would the nurse expect to observe? A. Frenzied and purposeless movements B. Exaggerated suspiciousness C. Stuporous withdrawal D. Sexual preoccupation
ANS: C Stuporous withdrawal, hallucinations, and delusions are characteristics of catatonic schizophrenia.
A client diagnosed with avoidant personality disorder states, I've never been close to my daughter. I'm sure she will never have time for me. Which nursing diagnosis applies to this client? a. Relocation stress syndrome b. Risk for violence: other directed c. Social withdrawal d. Fear
ANS: C The statement presented in the question suggests feelings of rejection leading to social withdrawal. The individual diagnosed with avoidant personality disorder is extremely sensitive to rejection and because of this, experiences a very socially withdrawn life. There may be a strong desire for companionship but extreme shyness and fear of rejection creates a need for unusually strong guarantees of uncritical acceptance.
Which statement is correct concerning personality disorders? a. Personality disorders generally emerge during adolescence b. Individuals diagnosed with personality disorders have insight into their disorder. c. Personality disorders occur when personality traits become inflexible and maladaptive d. Individuals diagnosed with personality disorders demonstrate adaptive ability to perceive and relate to themselves and the environment.
ANS: C When either significant functional impairment or subjective distress occurs as a result of inflexible and maladaptive personality traits, a diagnosis of personality disorder can be made.
A client diagnosed with Schizophrenia is experiencing disorganized thinking. Which technique should the nurse use to provide communication? A. Giving broad openings B. Probing C. Verbalizing the implied D. Using open-ended questions
ANS: C When working with clients who have greatly impaired communication, the nurse can use the technique of verbalizing the implied. By putting into words what the client may be experiencing, the nurse helps the client organize his or her thinking.
A newly admitted client has taken thioridazine (Mellaril) for 2 years with good symptom control. Symptoms exhibited on admission included paranoid delusions and hallucinations. The nurse should recognize which potential cause for the return of these symptoms? A. The client has developed tolerance to the antipsychotic medication. B. The client has not taken the medication with food. C. The client has not taken the medication as prescribed. D. The client has combined alcohol with the medication.
ANS: C Altered thinking can affect a client's insight into the necessity for taking antipsychotic medications consistently. When symptoms are no longer bothersome, clients may stop taking medications that cause disturbing side effects. Clients may miss the connection between taking the medications and an improved symptom profile.
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.
A client diagnosed with schizophrenia states, "Can't you hear him? It's the devil. He's telling me I'm going to hell." Which is the most appropriate nursing reply? A. "Did you take your medicine this morning?" B. "You are not going to hell. You are a good person." C. "I'm sure the voices sound scary. The devil is not talking to you. This is part of your illness." D. "The devil only talks to people who are receptive to his influence."
ANS: C The most appropriate reply by the nurse is to reassure the client with an accepting attitude while not reinforcing the hallucination. Reminding the client that "the voices" are a part of his or her illness is a way to help the client accept that the hallucinations are not real.
Parents ask a nurse how they should reply when their child, diagnosed with paranoid schizophrenia, tells them that voices command him to harm others. Which is the appropriate nursing reply? A. "Tell him to stop discussing the voices." B. "Ignore what he is saying, while attempting to discover the underlying cause." C. "Focus on the feelings generated by the hallucinations and present reality." D. "Present objective evidence that the voices are not real."
ANS: C The most appropriate response by the nurse is to instruct the parents to focus on the feelings generated by the hallucinations and present reality. The parents should maintain an attitude of acceptance to encourage communication but should not reinforce the hallucinations by exploring details of content. It is inappropriate to present logical arguments to persuade the client to accept the hallucinations as not real.
An aging client diagnosed with chronic schizophrenia takes an antipsychotic and a beta-adrenergic blocking agent (propranolol) for hypertension. Understanding the combined side effects of these drugs, which statement by a nurse is most appropriate? A. "Make sure you concentrate on taking slow, deep, cleansing breaths." B. "Watch your diet and try to engage in some regular physical activity." C. "Rise slowly when you change position from lying to sitting or sitting to standing." D. "Wear sunscreen and try to avoid midday sun exposure."
ANS: C The most appropriate statement by the nurse is to instruct the client to rise slowly when changing positions. Antipsychotic medications and beta blockers cause a decrease in blood pressure. When given in combination, this side effect places the client at risk for developing orthostatic hypotension.
A client diagnosed with paranoid schizophrenia states, "My psychiatrist is out to get me. I'm sad that the voice is telling me to stop him." What symptom is the client exhibiting, and what is the nurse's legal responsibility related to this symptom? A. Magical thinking; administer an antipsychotic medication B. Persecutory delusions; orient the client to reality C. Command hallucinations; warn the psychiatrist D. Altered thought processes; call an emergency treatment team meeting
ANS: C The nurse should determine that the client is exhibiting command hallucinations. The nurse's legal responsibility is to warn the psychiatrist of the potential for harm. A client who is demonstrating a risk for violence could potentially become physically, emotionally, and/or sexually harmful to others or to self.
A client diagnosed with schizophrenia is slow to respond and appears to be listening to unseen others. Which medication should a nurse expect a physician to order to address this type of symptom? A. Haloperidol (Haldol) to address the negative symptom B. Clonazepam (Klonopin) to address the positive symptom C. Risperidone (Risperdal) to address the positive symptom D. Clozapine (Clozaril) to address the negative symptom
ANS: C The nurse should expect the physician to order risperidone (Risperdal) to address the positive symptoms of schizophrenia. Risperidone (Risperdal) is an atypical antipsychotic used to reduce positive symptoms, including disturbances in content of thought (delusions), form of thought (neologisms), or sensory perception (hallucinations).
A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be taught by the nurse? A. The side effects of medications B. Deep breathing techniques to decrease stress C. How to make eye contact when communicating D. How to be a leader
ANS: C The nurse should plan to teach the client how to make eye contact when communicating. Social skills, such as making eye contact, can assist clients in communicating needs and maintaining connectedness.
A client diagnosed with psychosis NOS (not otherwise specified) tells a nurse about voices telling him to kill the president. Which nursing diagnosis should the nurse prioritize for this client? A. Disturbed sensory perception B. Altered thought processes C. Risk for violence: directed toward others D. Risk for injury
ANS: C The nurse should prioritize the diagnosis risk for violence: directed toward others. A client who hears voices telling him to kill someone is at risk for responding and reacting to the command hallucination. Other risk factors for violence include aggressive body language, verbal aggression, catatonic excitement, and rage reactions.
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 client diagnosed with schizophrenia takes an antipsychotic agent daily. Which assessment finding should a nurse immediately report to the client's attending psychiatrist? A. Respirations of 22 beats/minute B. Weight gain of 8 pounds in 2 months C. Temperature of 104F (40C) D. Excessive salivation
ANS: C When assessing a client diagnosed with schizophrenia who takes an antipsychotic agent daily, the nurse should immediately address a temperature of 104F (40C). A temperature this high can be a symptom of the rare but life-threatening neuroleptic malignant syndrome.
A client is being discharged on Haloperidol (Haldol). Which teaching should the nurse include about the medication? A. "If you forget to take your morning dose of Haldol, double the dose at bedtime." B. "Limit your alcohol intake to no more than 3 oz. per day." C. "When you go home, sit outside and enjoy the sunshine." D. "Do not stop taking Haldol abruptly."
ANS: D Abrupt withdrawal may precipitate nausea, vomiting, tremors, and lower the seizure threshold.
A client diagnosed with borderline personality disorder is admitted to a psychiatric unit. Which behavior pattern would the nurse expect to observe? a. Social isolation b. Suspicion of others c. Bizarre speech patterns d. Generating conflict among the staff
ANS: D Clients diagnosed with borderline personality disorder, having little empathy toward others, are unable to accept both positive and negative feelings and view others as all good or all bad. They tend to split staff, generating conflict.
The nurse determines which medication will give the client the most immediate relief from neuroleptic-induced extrapyramidal side effects (EPS)? A. Lorazepam (Ativan) 1mg PO B. Diazepam (Valium) 5 mg PO C. Haloperidol (Haldol) 2 mg PO D. Benztropine (Cogentin) 2 mg PO
ANS: D Cogentin parenterally is the drug of choice for this client. It is the first-line choice of drugs for extrapyramidal symptoms associated with the use of neuroleptics.
To deal with a client's hallucinations therapeutically, which nursing intervention should be implemented? A. Reinforce the perceptual distortions until the client develops new defenses B. Provide an unstructured environment C. Avoid making connections between anxiety-producing situations and Hallucinations D. Distract the client's attention
ANS: D Distract the client's attention by providing a competing stimulus that is stronger than the hallucination. Distracting the client to reality-based activities is helpful in reducing hallucinations.
A 68-year-old woman with a history of multiple divorces is admitted after phoning her daughter stating, "I have nothing to live for and am going to swallow a bottle of sleeping pills." This woman is struggling with which of Erikson's developmental task conflicts? a. Trust versus mistrust b. Industry versus inferiority c. Generativity versus stagnation d. Ego integrity versus despair
ANS: D Ego integrity versus despair occurs in the last years of life (ages 65 and older). The older adult reflects back on life and either derives pleasure and meaning from past events or feels self-contempt, anger, and depression when focusing on past failures. When the mother states, "I have nothing left to live for," she is demonstrating despair in the self-assessment of her life.
A single man lives with his mother. His father died when he was 6 years old. Using psychoanalytic theory, the nurse determines that the timing of this man's father's death may have caused problems with which developmental response? a. Resolution of an Electra complex b. Resolution of the oral stage c. Resolution associated with latency d. Resolution of an Oedipus complex
ANS: D Freud describes the Oedipus complex, which occurs during the phallic stage of development. The male child experiences an unconscious desire to eliminate the parent of the same gender and to possess the parent of the opposite gender for himself. Resolution of this internal conflict occurs when the child develops a strong identification with the parent of the same gender. At the age of 6 years, the death of this man's father could have negatively affected his identification with the same-sex parent.
A client is experiencing delusions and paranoia. What behaviors would the client exhibit? A. Altered speech and extreme suspiciousness B. Psychomotor retardation C. Regressive and primitive behaviors D. Anger and aggressive acts
ANS: D The paranoid client is often angry, aggressive, and guarded. Therefore the nurse must assess for these characteristics in order to ensure safety for the client and self.
Which nursing intervention would be most appropriate when caring for an acutely agitated client diagnosed with paranoid schizophrenia? 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 client's boundaries.
ANS: D The most appropriate nursing intervention is to provide personal space to respect the client's boundaries. Providing personal space may serve to reduce anxiety and thus reduce the client's risk for violence.
A nurse is assessing a client diagnosed with paranoid 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. Paranoid delusions 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.
A client diagnosed with chronic schizophrenia 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 and treat by discontinuing antipsychotic medications B. Agranulocytosis and treat by administration of clozapine (Clozaril) C. Extrapyramidal symptoms and treat by administration of benztropine (Cogentin) D. Tardive dyskinesia and treat by discontinuing antipsychotic medications
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.
During an admission assessment, a nurse notes that a client diagnosed with schizophrenia has allergies to penicillin, prochlorperazine (Compazine), and bee stings. Based on this assessment data, which antipsychotic medication would be contraindicated? A. Haloperidol (Haldol), because it is used only in elderly patients B. Clozapine (Clozaril), because of a cross-sensitivity to penicillin C. Risperidone (Risperdal), because it exacerbates symptoms of depression D. Thioridazine (Mellaril), because of cross-sensitivity among phenothiazines
ANS: D The nurse should know that thioridazine (Mellaril) would be contraindicated because of cross-sensitivity among phenothiazines. Prochlorperazine (Compazine) and thioridazine are both classified as phenothiazines.
