Chapter 16 Schizophrenia

16. The client with schizophrenia tells the nurse that rats have started to eat the client's brain. Which will be the best response by the nurse? A. "Have you discussed this with your health care provider?" B. "How could that be possible?" C. "You cannot have rats in your brain." D. "You look OK to me." ​

Answer: A Rationale: This sounds like a new symptom, so talking with the health care provider is important; the client may need to have medication reevaluated. "How could that be possible," puts the client on the defensive and sounds accusatory. "You cannot have rats in your brain," refers to the response as being unbelievable. It may be preferable to say that you find it hard to believe. "You look OK to me," is inappropriate and not therapeutic. ​

15. A client diagnosed with schizophrenia is laughing and talking while sitting alone. Which is the best response by the nurse? A. "Can you share your joke with me?" B. To sit with the client quietly until the client is ready to talk. C. "Tell me what's happening." D. "You look lonely here. Let's join the others in the day room." ​

Answer: C Rationale: Having the client tell the nurse what is happening explores what the client is experiencing and engages the client in reality interaction. Referring to a joke makes the assumption that the client is laughing because of a joke that they heard, which is not likely the case. Silence is appropriate during client interactions, but the nurse should first attempt to verbally engage the client. Stating that the client appears lonely does not address the client's behavior. ​

6. The client with schizophrenia states, "I just don't know how to count. The sky turned to fire. I have a ball in my head." Which term does the nurse use to document this statement? A. Word salad B. Ideas of reference C. Delusional thinking D. Associative looseness ​

Answer: D Rationale: Associative looseness is demonstrated through fragmented or poorly related thoughts and ideas. The series of disconnected thoughts best exemplifies this concept. Some of the statements contain delusions or fixed false beliefs that have no basis in reality. Ideas of reference are false impressions that external events have special meaning for the person. Word salad involves stringing together words that are not connected in any way. ​

StartFragment 39. A nurse is working with a client diagnosed with schizophrenia who is not participating in group. The client seems to be indifferent to other people, and the nurse interprets this as a negative symptom. Which other negatives symptom(s) will the nurse assess for? Select all that apply. A. Catatonia B. Anhedonia C. Blunted affect D. Ideas of reference E. Ambivalence EndFragment

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41. A client is admitted with the diagnosis of possible schizophrenia and to rule out (R/O) organic pathology. Based on this information, what treatment will the nurse assist with for this client? A. Referral to a mental health specialist for extensive psychological testing. B Prepare the client for a computed tomography (CT) of the brain. C. Notify the lab for immunologic assay performed within 2 days of the admission. D. Perform a dexamethasone suppression test (DST). ​

Answer: B Rationale: The CT will reveal structural changes in the brain that might be responsible for symptoms of psychosis (e.g., abscess, tumor). Psychological testing may be performed but will be less definitive in ruling out organic pathology. Immunological studies are not indicated in ruling out the organic cause. The DST is related to depression. ​

40. A nurse is working with a client who has been diagnosed with delusional thoughts. Which is an initial short-term outcome appropriate for this client? A. Accept that the delusion is illogical B. Distinguish external boundaries C. Explain the basis for the delusions D. Engage in reality-oriented conversation ​

Answer: D Rationale: Delusions are not reality oriented; thus, an appropriate outcome would be that the client will engage in reality-oriented conversation rather than discussing delusional beliefs. Delusions are fixed, false beliefs. Clients rarely accept anyone using logic to dispute them. Data are not present to suggest boundary disturbance. Explaining the delusion is not progress; it suggests the client still holds to the belief. ​

30. The nurse receives hand-off report on clients with schizophrenia. Which client will the nurse assess first? A. A client with echolalia who is speaking loudly B. A client with catatonia who is lying in the bed in the fetal position C. A client who is making the movements and gestures of a roommate D. A client who laughs inappropriately to the behaviors of others ​

Answer: B Rationale: A client with catatonia who is lying in the bed in the fetal position is unable to meet their own self-care needs such as toileting, eating, drinking, or other functions. The client with echolalia is speaking loudly and repeating the words of another but is able to meet their own self-care needs. Making gestures and movements of a roommate is echopraxia and is not a safety issue at this time. Inappropriate laughter does not indicate that the client is unsafe at this time or likely to be of harm to self or others. ​

9. The nurse is performing a mental health assessment for a client with schizophrenia. Which statement made by the client demonstrates that the client is having auditory hallucinations? A. "Can you hear those children singing in the room with us?" B. "Those voices keep telling me that I need to get a knife and cut myself." C. "I keep smelling feces in the room, and I can't get the odor out of my nose." D. "I keep tasting things that are foul like onions and garlic but I don't eat those." ​

Answer: A Rationale: Auditory hallucinations, the most common type, involve hearing sounds, most often voices, talking to or about the client. Command hallucinations are voices demanding that the client take action, often to harm self or others, and are considered dangerous. Olfactory hallucinations involve smells or odors. Gustatory hallucinations involve a taste lingering in the mouth or the sense that food tastes like something else. ​

21. The nurse enters the room of a client with schizophrenia the day after the client has been admitted to an inpatient setting and says, "I would like to spend some time talking with you." The client stares straight ahead and remains silent. Which would be the best response by the nurse? A. "I can see you want to be alone. I'll come back another time." B. "You don't need to talk right now. I'll just sit here for a few minutes." C. "I've got some other things I can do now. I hope you'll feel like talking later." D. "You would feel better if you would tell me what you're thinking." ​

Answer: B Rationale: Establishing a therapeutic relationship involves spending time with the client, perhaps through fairly length periods of silence. Leaving the room when the client opts not to talk is likely an attempt to respect the client's wishes, but it severs contact and rapport building. It is not effective or therapeutic to plead with the client to speak or to convince them of the benefits. ​

10. A client with schizophrenia reads the advice column in the newspaper daily. The client states, "This person is my guide and tells me what I must do every day." Which is the best response by the nurse? A. "Can you tell me why you are so interested in the advice column?" B. "You must believe you are very famous for someone in the column to talk with you." C. "The author of that advice column is talking to anyone that is reading it and not only you." D. "You should take your own advice and not listen to someone that you don't even know." ​

Answer: A Rationale: Referential delusions or ideas of reference involve the client's belief that television broadcasts, music, or newspaper articles have special meaning for them. The nurse can ask the client why they are interested to clarify the meaning of the statement. Attempting to ridicule or demean the client by inferring that they are not famous for the author to give advice or that they are not talking to them is a nontherapeutic response. Arguing with the client about taking their own advice is nontherapeutic and a caustic response. ​

43. The nurse suspects that a client taking an antipsychotic medication for the treatment of schizophrenia is having drug-induced parkinsonism. Which finding(s) assessed by the nurse will correlate with this disorder? Select all that apply. A. Facial expressions are mask-like with little emotion observed. B. The fingers are making a pill rolling motion. C. The client is having drooling from the side of the mouth. D. The client has a resting heart rate of 102 beats per minute. E. The client demonstrates a slowness and difficulty initiating movements. ​

Answer: A, B, C, E Rationale: A masklike facies, cogwheel rigidity (ratchet-like movements of joints), drooling, muscle stiffness (continuous), and akinesia (slowness and difficulty initiating movement) are all symptoms of pseudoparkinsonism, or neuroleptic-induced parkinsonism. Tachycardia is not a symptom of pseudoparkinsonism. ​

StartFragment 12. The nurse is creating a plan of care for a client with schizophrenia. Which nursing intervention will the nurse perform first when caring for this client? A. Observe for signs of fear or agitation. B. Maintain reality through frequent contact. C. Encourage client to participate in the treatment milieu. D. Assess community support systems.

StartFragment Answer: A Rationale: Safety for both the client and the nurse is the priority when providing care for the client with schizophrenia. The nurse must observe for signs of building agitation or escalating behavior such as increased intensity of pacing, loud talking or yelling, and hitting or kicking objects. The nurse must then institute interventions to protect the client, nurse, and others in the environment. EndFragment

19. The nurse observes a client with schizophrenia sitting alone, laughing occasionally, and turning their head as if listening to another person. Which statement by the nurse is most appropriate? A. "Are you hearing something?" B. "It's a beautiful day, isn't it?" C. "Would you like to go to your room to talk?" D. "Would you like to take some of your PRN medication?" ​

StartFragment Answer: A Rationale: Asking whether the client is hearing something validates the nurse's assessment and focuses on the client's experience. The other choices do not address the situation of the client experiencing auditory hallucinations at the present time. Question format: Multiple Choice Chapter 16: Schizophrenia Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Learning Objective: 1 EndFragment Rationale: It is not possible for the client to speak meaningfully with others, express their feelings, or socialize without being oriented to reality. Consequently, reality orientation has the highest priority. Question format: Multiple Choice ​

33. The nurse is educating a client and family regarding the effects of antipsychotic medications. Which extrapyramidal symptom(s) that may be caused by antipsychotic drugs will the nurse include in the education plan? Select all that apply. A. Akathisia B. Pseudoparkinsonism C. Tardive dyskinesia D. Dystonia F. Neuroleptic malignant syndrome ​

Answer: A, B, C, D Rationale: Extrapyramidal symptoms include dystonia, pseudoparkinsonism, akathisia, and tardive dyskinesia. Neuroleptic malignant syndrome is also a side effect of antipsychotic drugs but is an idiosyncratic reaction to an antipsychotic drug, not an extrapyramidal symptom. Breast tenderness in men and women is also a potential side effect of antipsychotic drugs that cause elevated prolactin levels, but it is not an extrapyramidal symptom. ​

25. The nurse is evaluating the effectiveness of the antipsychotic medication a client is taking for the treatment of schizophrenia. Which question(s) will be of most benefit to determine the effectiveness? Select all that apply. A. "Have the symptoms you were experiencing disappeared?" B. "Are you able to carry out your daily life despite the persistence of some psychotic symptoms?" C. "Are you committed to taking the medication as prescribed?" D. "Are you satisfied with your quality of life?" E. "Do you have access to community agencies that will help you to live successfully in this community?" ​

Answer: A, B, C, D Rationale: The client's perception of the success of treatment plays a part in evaluation. In a global sense, evaluation of the treatment of schizophrenia is based on the following: Have the client's psychotic symptoms disappeared? If not, can the client carry out their daily life despite the persistence of some psychotic symptoms? Does the client understand the prescribed medication regimen? Are they committed to adherence to the regimen? Does the client believe that they have a satisfactory quality of life? Do you have access to community agencies that will help you to live successfully in this community? An appropriate question to ask to evaluate the plan of care but does not directly relate to antipsychotic medications. ​

7. A client with schizophrenia demonstrates very little emotional expression when in a group session with others. Which characteristic(s) will the nurse document regarding the clients assessed affect? Select all that apply. A. Flat B. Blunt C. Bright D. Inappropriate E. Pleasant ​

Answer: A, B, D Rationale: Clients with schizophrenia are often described as having blunted affect (few observable facial expressions) or flat affect (no facial expression). The client may exhibit an inappropriate expression or emotions incongruent with the context of the situation. A bright affect would suggest a high level of expression and engagement, which is uncommon in clients with schizophrenia. Similarly, an affect that is described as "pleasant" would most likely denote happiness and high engagement, which are unlikely in clients who have schizophrenia. ​

23. When planning the discharge for a client with schizophrenia, the nurse identifies barriers to the client's ability to adhere to the medication regimen. Which characteristic(s) improves the likelihood that the client will follow the prescribed medication regimen? Select all that apply. A. Short-term memory intact B. History of missing appointments C. Receives monthly disability checks D. Walking as primary mode of transportation E. Location of pharmacy nearest the client's residence ​

Answer: A, C, E Rationale: Numerous factors influence whether a client will adhere to a medication regimen. Intact memory, a predictable source of finances, and ready access to a pharmacy are factors that increase the likelihood of adherence. Missed appointments suggest unpredictability and instability, factors that are associated with nonadherence. Transportation challenges can inhibit adherence; if the client has no access to transportation apart from walking, there is an increased risk for nonadherence. ​

26. A client with schizophrenia has returned to the clinic because of worsening of symptoms. The client reports they stopped taking the medication because the client did not like the side effects. When educating the client regarding the management of side effect, what information will be included? Select all that apply. A. Suck on hard candy to treat dry mouth. B. Spend at least 30 minutes outside in the sun daily. C. Use stool softeners as needed for constipation. D. Decrease the amount of daily fluid intake. E. Maintain a balanced calorie-controlled diet. ​

Answer: A, C, E Rationale: Unwanted side effects are frequently reported as the reason clients stop taking medications. Interventions, such as eating a proper diet and drinking enough fluids, using a stool softener to avoid constipation, sucking on hard candy to minimize dry mouth, or using sunscreen to avoid sunburn, can help control some of these uncomfortable side effects. Weight gain can be an unpleasant side effect and the use of a calorie-controlled, balanced diet may be helpful in control of weight gain. ​

5. A client diagnosed with paranoid schizophrenia states, "Those people are with the CIA and are spying on me." Which response by the nurse is most therapeutic? A. "You are experiencing paranoia. Those people aren't after you." B. "I find it difficult to believe that this is occurring." C. "You must believe that you are really important for the CIA to spy on you." D. "Did you do something wrong that you are being spied on?" ​

Answer: B Rationale: Delusions are fixed false beliefs that have no basis in reality. By telling the client that it is difficult to believe this is occurring, as the client begins to trust you, they may become willing to doubt the delusion if you express your doubt. Inferring that the client is paranoid places a label on the client and will disrupt the development of the nurse-client relationship. Demeaning the client by telling them that they must be really important is nontherapeutic and may prevent the client from discussing future delusions with the nurse. Asking the client if they did something wrong supports the delusion, which is nontherapeutic. ​

4. The client taking antipsychotic medications for the treatment of schizophrenia informs the nurse that the side effect of weight gain is making them question whether they want to continue taking it. Which is the best response by the nurse? A. "If you don't take your medication, you will start hallucinating and not be able to care for yourself." B. "Try and eat a balanced nutritional diet with portion control and practice regular exercise." C. "We can look into medication for weight loss or weight loss surgery to help with the gain." D. "Everyone gains weight from these medications but it is better than the alternative." ​

Answer: B Rationale: The initial intervention is to discuss the initiation of a balanced and nutritious diet with regular exercise to help prevent further weight gain. Weight gain is a common side effect, but not all clients do gain weight. Medication for weight loss may have other side effects and may not be a viable option with antipsychotic medications. Weight loss surgery is not an option for all clients and should only be considered as a last resort. ​

2. The nurse is providing education for a client who is taking benztropine to prevent the extrapyramidal side effects from taking a traditional antipsychotic medication. Which will the nurse include when discussing side effects of the medication? Select all that apply. A. Akathisia is a common side effect of the medication and will go away 2 weeks after starting B. Increase fluid and fiber intake to prevent constipation. C. Use ice chips or sugar free hard candy to help with dry mouth. D. Report any signs of memory impairment that may be a side effect of the medication. E. Take the benztropine only when experiencing tremors or muscle rigidity. ​

Answer: B, C, D Rationale: The anticholinergic effects of the medication will cause dry mouth, and the best way for the client to counteract this effect is to use ice chips or sugar free candy or gum. Increase fluid and fiber intake to avoid constipation and assess for memory impairment that is also a side effect of the medication. Akathisia is not a side effect that will just dissipate in 2 weeks and should be reported to the health care provider. The benztropine should be taken as prescribed and not on an as-needed basis. ​

28. The parents of a young adult who has schizophrenia ask how they can recognize when their child is beginning to relapse. Which will the nurse educate the parents about which to assess for? Select all that apply. A. Excessive sleeping B. Fatigue C. Irritability D. Increased inhibition E. Negativity ​

Answer: B, C, E Rationale: Teaching the client and family members to prevent or manage relapse is an essential part of a comprehensive plan of care. This includes providing facts about schizophrenia, identifying the early signs of relapse, and teaching health practices to promote physical and psychological well-being. Early signs of relapse include impaired cause-and-effect reasoning, impaired information processing, poor nutrition, lack of sleep, lack of exercise, fatigue, poor social skills, social isolation, loneliness, interpersonal difficulties, lack of control, irritability, mood swings, ineffective medication management, low self-concept, looking and acting different, hopeless feelings, loss of motivation, anxiety and worry, disinhibition, increased negativity, neglecting appearance, and forgetfulness. ​

18. A client with schizophrenia is reluctant to take prescribed oral medication. Which is the most therapeutic response by the nurse to this refusal? A. "I can see that you're uncomfortable now, so we can wait until tomorrow." B. "If you refuse these pills, you'll have to get an injection." C. "What is it about the medicine that you don't like?" D. "You know you have to take this medicine for your own good." ​

Answer: C Rationale: Asking the client why the client does not like the medication explores the client's reason for refusal, which is the first step in resolving the issue. The nurse must determine the barriers to compliance for each client. Threatening the client with an injection is assault. Waiting until tomorrow puts off the inevitable. Telling the client it is for the client's own good is not the most therapeutic response in order to get the client to take medication. ​

32. The client with schizophrenia behaves as though the nurse is not trustworthy or that the nurse is questioning their integrity. Which assumption will the nurse make when interacting with this client? A. The client is correct, and the nurse lacks trustworthy behavior. B. The client is deliberately attempting to manipulate the nurse. C. The client's behavior is a part of the disorder and should not be taken personally. D. The nurse's actions have failed to improve the client's disorder through treatment. ​

Answer: C Rationale: Suspicious or paranoid behavior on the client's part may make the nurse feel as though they are not trustworthy or that their integrity is being questioned. The nurse must recognize this type of behavior as part of the illness and not interpret or respond to it as a personal affront. The nurse must not take responsibility for the success or failure of treatment efforts or view the client's status as a personal success or failure. ​

37. The nurse is preparing to administer thiothixene to a client with schizophrenia and assesses muscle rigidity, a temperature of 103°F (39.4°C), an elevated serum creatinine phosphokinase level, stupor, and urinary incontinence. Which is the priority action by the nurse? A. Administer diphenhydramine IM. B. Administer the medication and notify the health care provider. C. Hold the medication and notify the health care provider. D. Administer benztropine IM. ​

Answer: C Rationale: The client demonstrates all the classic signs of neuroleptic malignant syndrome (NMS). The medication should not be administered, and the provider should immediately be notified. This can be a fatal reaction to the antipsychotic medication. Any of the antipsychotic medications can cause NMS, which is treated by stopping the medication. The client's ability to tolerate other antipsychotic medications after NMS varies, but the use of another antipsychotic appears possible in most instances. Diphenhydramine and benztropine are administered for the treatment of dystonia but will not be effective for NMS. ​

14. A client states, "I am dead. I have come back from the dead." Which is the most appropriate response by the nurse? A. "What is it like to feel dead?" B. "No you didn't. People don't come back from the dead." C. "Show me what you did in art therapy this morning." D. "I'll get your medicine and you'll feel better." ​

Answer: C Rationale: The client experiencing delusions believes them and cannot be convinced they are false or untrue. It is the nurse's responsibility to present and maintain reality by making simple statements. Asking the client what they did in art therapy will have the client present the reality. The nurse must avoid openly confronting the delusion or arguing with the client about it. The nurse must also avoid reinforcing the delusional belief by "playing along" with what the client says. Inferring that the client is not feeling well supports the delusion of death. ​

31. A novice nurse is having a first experience in an inpatient psychiatric unit and is frightened by the behavior of a client with schizophrenia. The nurse will take which action to deal with fear? A. Express fear to the psychiatrist during rounds B. Pretend to not be afraid C. Stay in an open area while talking with the client D. Insist that another nurse accompany the novice nurse at all times ​

Answer: C Rationale: The novice nurse may be genuinely frightened or threatened if the client's behavior is hostile or aggressive. The novice nurse must acknowledge these feelings and take measures to ensure their safety. This may involve talking to the client in an open area rather than in a more isolated location or having an additional staff person present rather than being alone with the client. If the novice nurse pretends to be unafraid, the client may sense the fear anyway and feel less secure, leading to a greater potential for the client to lose personal control. It is not possible for a seasoned nurse to accompany the novice nurse at all times. ​

8. A client with schizophrenia is having a conversation with the nurse. Which behavior does the nurse identify that demonstrates the client is likely experiencing thought blocking? A. The client states, "Those people are taking my thoughts away." B. The client states, "Other people are putting thoughts in my head." C. The client stops talking in the middle of a sentence and is silent for 1 minute. D. The client states, "I think other people can hear my thoughts." ​

Answer: C Rationale: The nurse can assess thought content by evaluating what the client actually says. For example, clients may suddenly stop talking in the middle of a sentence and remain silent for several seconds to 1 minute (thought blocking). They may also state that they believe others can hear their thoughts (thought broadcasting), that others are taking their thoughts (thought withdrawal), or that others are placing thoughts in their mind against their will (thought insertion). ​

11. The nurse admits a client to psychiatric rehabilitation after being diagnosed with new-onset schizophrenia. Which outcome(s) does the nurse plan for the client to achieve from this program? Select all that apply. A. The client will be free from exacerbations of illness. B. The client will no longer require medications to control symptoms. C. The client will be able to continue to live independently. D. The client will participate in making treatment decisions. E. The client will have an improved quality of life. ​

Answer: C, D, E Rationale: Psychiatric rehabilitation has the goal of recovery for clients with major mental illness that goes beyond symptom control and medication management. Working with clients to manage their own lives, make effective treatment decisions, and have an improved quality of life—from the client's point of view—are central components of such programs. It is not realistic to believe that the client will no longer have exacerbations since the disorder is chronic and progressive and will be difficult to control without medication. ​

38. The nurse is educating a client taking clozapine. Which statement made by the client indicates that the education is effective? A. "I can get a supply of the medication for 90 days at a time." B. "I need to have monthly neutrophil tests for up to a year." C. "I may have a fatal response if I go outside and develop a rash." D. "I should call the health care provider if I develop a sore throat and fever." ​

Answer: D Rationale: Clozapine produces fewer traditional side effects than do most antipsychotic drugs, but it has the potentially fatal side effect of agranulocytosis. This develops suddenly and is characterized by fever, malaise, ulcerative sore throat, and leukopenia. This side effect may not be manifested immediately and can occur up to 24 weeks after the initiation of therapy. Any symptoms of infection must be investigated immediately. Agranulocytosis is characterized by fever, malaise, ulcerative sore throat, and leukopenia. Clients taking this antipsychotic must have weekly absolute neutrophil counts (ANC) for the first 6 months of clozapine therapy and every 2 weeks for 6 months, and monthly thereafter (provided ANC is in acceptable range). Clozapine is dispensed every 7 or 14 days or monthly only, and evidence of an ANC of 1,500 µL (1.5 x 109/L) (1,000 µL [1.0 x 109/L] for benign ethnic neutropenia) is required before a refill is furnished. Photosensitivity is a mild sensitivity reaction and not cause for alarm. ​

29. The nurse is reviewing administration of an antipsychotic medication with a client prior to discharge. The client asks the nurse upon discharge, "What should I do if I forget to take my medicine?" Which is the best response by the nurse? A. "Just double the dose next time it is scheduled." B. "Skip that dose and resume your regular with the next dose." C. "Don't miss doses, or you will not maintain therapeutic drug levels." D. "Do not take a dose if you remember it more than 4 hours after it was due." ​

Answer: D Rationale: If a client forgets a dose of antipsychotic medication, advise the client to take it if the dose is only 3 to 4 hours late. If the missed dose is more than 4 hours late or the next dose is due, ask the client to omit the forgotten dose. Doubling a dose is unsafe and should not be recommended by the nurse. The client should only skip a missed dose if 3 or 4 hours have elapsed since it was due. Cautioning the client against missing doses does not answer the client's question. ​

36. The client with schizophrenia taking antipsychotic medication is conversing with the nurse when the eye's roll back in a locked position. Which is the priority action by the nurse? A. Place the client on seizure precautions. B. Refer the client to the ophthalmologist. C. Advocate for an increase in the antipsychotic medication. D. Administer diphenhydramine IM immediately. ​

Answer: D Rationale: Oculogyric crisis is the occurrence of the eye rolling back in a locked position, which occurs with acute dystonia. Acute treatment consists of diphenhydramine (Benadryl) given either intramuscularly or intravenously, or benztropine (Cogentin) given intramuscularly. The client is not experiencing a seizure at this time, and the issue is not a dysfunction of the eye itself. The cause of the issue is the antipsychotic medication, and the increased dose would create more dystonia. ​

34. A client with severe and persistent mental illness has been taking antipsychotic medication for 20 years. The nurse observes during a therapy session that the client's behavior includes repetitive movements of the mouth and tongue, facial grimacing, and rocking back and forth. Which action will the nurse take to address these findings? A. Stop the medication immediately and inform the health care provider. B. Request the client make an effort to remain still for 15 minutes. C. Administer haloperidol IM to stop the movements. D. Assess the client using the Abnormal Involuntary Movements Scale (AIMS). ​

Answer: D Rationale: The client's behaviors are classic signs of tardive dyskinesia. Tardive dyskinesia, a syndrome of permanent involuntary movements, is most commonly caused by the long-term use of conventional antipsychotic drugs. The client should be assessed using the AIMS tool, and a score increase from the baseline should be reported to the health care provider. The client is not able to voluntarily control the movements and will be unable to complete the request to remain still for 15 minutes. The nurse should not request that the client stop the medication at this time and report the finding to the provider for further instructions. Haloperidol is used to control psychotic behavior and may further worsen the movements. ​

1. A nurse is talking with a client who is diagnosed with schizophrenia. The client' speech becomes aggressive, and the nurse feels threatened. Which is the priority action by the nurse? A. Approach the client and touch their arm to signify the nurse is not a threat. B. Inform the client that if they continue to be aggressive, they will be restrained. C. Ask another nurse to prepare an injection of haloperidol for aggressiveness. D. Acknowledge feelings of fear and take measures to ensure safety. ​

StartFragment Answer: D Rationale: The nurse may be genuinely frightened or threatened if the client's behavior is hostile or aggressive. The nurse must acknowledge these feelings and take measures to ensure their safety. This may involve talking to the client in an open area rather than in a more isolated location or having an additional staff person present rather than being alone with the client. If the nurse pretends to be unafraid, the client may sense the fear anyway and feel less secure, leading to a greater potential for the client to lose personal control. Touch is not used with an aggressive client and may accelerate behaviors. The client should not be threatened with physical or chemical restraint. End Fragment

StartFragment 17. A client who is suspicious has been placed in a room with a roommate. The night nurse assesses the situation and reports that this client has been awake for the past 3 nights. For which behaviors will the nurse assess for the client's wakefulness? A. The client is fearful of what the roommate might do to the client while sleeping. B. The client is a light sleeper and unaccustomed to a roommate. C. The client is watching for an opportunity to escape. D. The client is worrying about family problems. EndFragment

StartFragment Answer: A Rationale: Clients who have suspicion trust no one and believe others are going to harm them. It is plausible that this client has a fear of being harmed. Pondering an escape, being a light sleeper and unaccustomed to a roommate, and worrying about family problems are less likely manifestations of suspicion, which is the defining characteristic of this client. EndFragment

13. A client with schizophrenia is seen sitting alone and talking out loud. Suddenly, the client stops and turns as if listening to someone. The nurse approaches and sits down beside the client. Which is the best response by the nurse? A. "You must be pretty bored to be sitting here talking to an invisible person." B. "I don't hear or see anyone else; what are you hearing and seeing?" C. "I can tell you are hearing voices, but they are not real." D. "How long have you known the person you are talking to?" ​

StartFragment Answer: B Rationale: Intervening when the client experiences hallucinations requires the nurse to focus on what is real and to help shift the client's response toward reality. Initially, the nurse must determine what the client is experiencing—that is, what the voices are saying or what the client is seeing. As well, the nurse should state clearly that they do not share the hallucination. Referencing an "invisible person" is nontherapeutic because it is dismissive of the client's reality and is likely to cause the client to become defensive. It is ineffective and nontherapeutic to try to rationally explain that hallucinations are not real. "How long have you known the person you are talking to?" would reinforce the client's hallucination, which is not therapeutic. EndFragment

StartFragment 35. A client with schizophrenia is seen in the outpatient clinic for a follow-up appointment to assess the effectiveness of a recent increase in the dose of fluphenazine. Which assessment data by the nurse is a priority to address? A. The client has a weight gain of 3 lbs. in 3 weeks. B. The client informs the nurse they are taking a stool softener for constipation. C. The client reports a dry mouth. D. The client is restless and agitated and states, "I can't remain still." EndFragment

StartFragment Answer: D Rationale: Akathisia is reported by the client as an intense need to move about. The client appears restless or anxious and agitated, often with a rigid posture or gain and a lack of spontaneous gestures. Akathisia usually develops when the antipsychotic is started or when the dose is increased. Clients are typically uncomfortable with these sensations and may stop taking the antipsychotic medication to avoid these side effects. Beta-blockers such as propranolol have been most effective in treating akathisia, and benzodiazepines have provided some success as well. This is the most important issue for the nurse to address. The dry mouth, weight gain, and taking the stool softeners are mild side effects of the antipsychotic. EndFragment

StartFragment 24. A client with schizophrenia is attending a follow-up appointment at the community mental health clinic. The client reports to the nurse, "I stopped taking the antipsychotic medication because I can't get an erection with my partner anymore." Which response by the nurse will enhance the client's well-being? A. "It sounds like that is a problem for you. Don't you still find them to be sexy enough?" B. "Sexual dysfunction is a temporary side effect and should get better once your body is used to the medication." C. "You should avoid having sex with your partner anyway. Do you really want them to get pregnant?" D. "It is important for you to take an antipsychotic medication, but perhaps a different type will be less likely to affect your sexual functioning. I would like to call your health care provider about this." EndFragment

StartFragment Answer: D Rationale: Some side effects, such as those affecting sexual functioning, are embarrassing for the client to report, and the client may confirm these side effects only if the nurse directly inquires about them. This may require a call to the client's health care provider or primary provider to obtain a prescription for a different type of antipsychotic. Asking if the client finds their partner "sexy" is irrelevant and inappropriate. Sexual side effects are not necessarily self-limiting and may persist over time. There is no need to caution the client against having sex. As well, this response downplays the client's concern. EndFragment

20. A client with schizophrenia is admitted to the inpatient unit. The client does not speak when spoken to but is observed talking to themselves on occasion. Which is the priority outcome at this time? A. The client will begin talking with other clients. B. The client will express feelings freely. C. The client will increase socialization with others. D. The client will increase reality orientation. ​

Answer D

22. A client with schizophrenia leaves the room and begins marching in the hall. When approached by the nurse, the client says, "God says I'm supposed to guard the area." Which response would be best? A. "I understand you hear a voice. You and I are the only ones in the hall, and I don't hear a voice." B. "The voices are part of your illness, and they will leave in time." C. "This guarding responsibility can make you tired. You rest for now, and I'll guard a while." D. "You are just imagining these things. Do not pay any attention to the voices." ​

Answer: A Rationale: Acknowledging that the client hears a voice validates that the client's experience is real to the client, while also presenting reality. "The voices are part of your illness, and they will leave in time," is not appropriate to the client's statement. "This guarding responsibility can make you tired. You rest for now, and I'll guard a while," reinforces the client's delusion. "'You are just imagining these things. Do not pay any attention to the voices," does not deal with the client in a serious manner. ​

StartFragment most consistent with this symptom? A. "I can understand why my spouse is upset that I overspend." B. "I can't do anything anymore." C. "I'm the world's most astute financier." D. "I can't understand where all the money in our family goes." EndFragment

Answer: C Rationale: Grandiose delusions are characterized by the client's claim to association with famous people or celebrities, or the client's belief that they are famous or capable of great feats. For example, the client may claim to be engaged to a famous movie star or related to a public figure. An individual who is demonstrating grandiosity has an exaggerated view of their abilities. The other options are more moderate statements and lack the element of exaggeration. ​

3. The nurse is evaluating several clients with a diagnosis of schizophrenia. Which client will be assessed as having the worst potential outcomes? A. A client who has a first cousin with bipolar I disorder B. A client with an exacerbation of hallucinations and delusion 2 years after diagnosis C. An older adult client with an onset of positive symptoms at age 35 D. An adolescent client with alogia, anhedonia, and a flat or blunted affect ​

Answer: D Rationale: When and how the illness develops seems to affect the outcome. Age at onset appears to be an important factor in how well the client fares; those who develop the illness earlier show worse outcomes than those who develop it later. Younger clients display a poorer premorbid adjustment, more prominent negative signs, and greater cognitive impairment than do older clients. Those who experience a gradual onset of the disease (about 50%) tend to have a poorer immediate- and long-term course than those who experience an acute and sudden onset. The adolescent client who has negative signs would be at the greatest risk for the worst outcomes. A first cousin with bipolar I disorder, older client with a late onset, and the client who has an exacerbation after 2 years would have a better prognosis. ​

27. The nurse is working with a client who has schizophrenia, disorganized type. It is time for the client to get up and eat breakfast. Which statement by the nurse would be most effective in helping the client prepare for breakfast? A. "I'll expect you in the dining room in 20 minutes." B. "It's time to put your clothes on now." C. "Stay right there and I'll get your clothes for you." D. "Why don't you stay here and I'll get your tray for you." ​

StartFragment Answer: B Rationale: Clients with schizophrenia may have significant self-care deficits. The client needs clear direction, with tasks broken into small steps, to begin to participate in the client's own self-care. The other choices do not support the client effectively. "I'll expect you in the dining room in 20 minutes," is authoritarian and does not allow the client dignity. "Stay right here, and I'll get your clothes for you," is also authoritarian and does not allow the client dignity. "Why don't you stay here and I'll get your tray for you," is kinder, but it robs the client of the opportunity to do for themself as much as possible. EndFragment