EAQ: Psychosis

A client with schizophrenia is admitted to a psychiatric unit. The client is talking while walking in the hall, is unkempt, and obviously has not washed in several says. Which response by the nurse is most likely to encourage this client to shower?

"I'll help you take your shower now."

A confused, hallucinating client says, "My arms are turning to stone."

"It can be frightening to feel that way."

One morning a female client with the diagnosis of schizophrenia tells the nurse that she is Joan of Arc and is going to be burned at the stake. Which response by the nurse is most therapeutic?

"It seems like the world is a pretty scary place for you."

A client with schizophrenia has reported ongoing hallucinations that "say I am a bad person." After confirming with the client that these are not command hallucinations, which response by the nurse is most appropriate?

"Try to ignore the voices."

A client diagnosed with schizophrenia, paranoid type, states to the nurse, "I know they're spying on me in here, too. I'm not safe anywhere." Which response is therapeutic?

"You don't feel safe anywhere, not even in the hospital?"

Which characteristic accurately describes delusions according to the psychodynamic theory?

A defense against anxiety

Which information would the nurse distinguish as important when preparing to give an intramuscular injection to an 8-year-old child for an acute episode of psychosis?

A deltoid injection in a child should be given in the thickest part of the muscle.

Which clinical manifestation best indicates improvement in the mental status of a client diagnosed with schizophrenia, paranoid type?

Ability to function effectively in activities of daily living

Which nursing approach should be implemented first when caring for a client who presents as self-accusatory and guilt-ridden?

Accept the client's statements as the client's beliefs.

The nurse is working with a group of clients in a mental health facility. Which condition will lead the nurse to assess for suicide risk? (Select all that apply) Anxiety Alcohol abuse Schizophrenia Bipolar disorder Attention deficit disorder

Alcohol abuse Schizophrenia Bipolar disorder

Which intervention would the nurse implement as directed when finding poor skin turgor and scanty urine output on assessment of a client experiencing a psychotic episode? (Select all that apply.) Turn at least every 2 hours (q 2 h) Initiate input and output recording Watch urine output closely Perform neurologic assessment every four hours (q 4 h) Encourage oral fluids in small amounts Give intravenous (IV) solution at 125 mL per hours as prescribed

All of the above

A client with schizophrenia is unable to feel happiness and joy. Which symptom does this describe?

Anhedonia

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

Apathy Flatness

Which response by the nurse demonstrates an understanding of a client's hallucinating behavior?

Asking, "What are the voices telling you to do?"

Which action of neuroleptic drugs prescribed schizophrenic clients promotes mental health?

Blocking access to dopamine receptors at the postsynaptic receptor site

Which behavior correctly describes what a client is experiencing when making the statement, "I hear my decreased son telling me to come over to the other side"?

Command hallucination

A client has been prescribed chlorpromazine for the management of positive symptoms of schizophrenia. Which action will the nurse take if the client reports difficulty sustaining an erection?

Consult with his provider regarding alternative medication therapies.

A client's parents ask about the treatment of their child who has a recent diagnosis of schizophrenia. Which information should the nurse consider before responding?

Drug therapy, although it does not eliminate the underlying problem, reduces the symptoms of acute schizophrenia

A client is admitted to the acute care psychiatric unit with a diagnosis of panic disorder with agoraphobia. Which intervention should the nurse implement during the initial assessment phase?

Ease the client's anxiety so further interviewing may be done.

A client is being admitted to the psychiatric unit. Which clinical manifestation does the nurse expect to assess in a client with a diagnosis of undifferentiated schizophrenia? (Select all that apply.) Exited behaviors Loose associations Inappropriate affect Feelings of depression Hypervigilant behavior

Exited behaviors Loose associations Inappropriate affect

When a client is breastfeeding, which medication can place the infant at risk?

Fluoxetine

Which prescription medication may be best for a client diagnosed with schizophrenia who forgets to take medications?

Fluphenazine

Which activity is most therapeutic for a withdrawn client exhibiting hallucinations?

Go for a walk with the nurse.

Which description is documented by the nurse when the client says, "That man on the TV is talking only to me"?

Idea of reference

A client with schizphrenia sees a group of visitors sitting together talking. The client tells the nurse, "I know they're talking about me." Which altered thought process should the nurse identify?

Ideas of reference

A young client is admitted to the hospital with a diagnosis of acute schizophrenia. the family reports that one day the client looked at a linen sheet on a clothesline and thought it was a ghost. Which is the most appropriate conclusion to make about what the client was experiencing?

Illusion

Which goal of medication therapy will the nurse discuss with family about a client with schizophrenia who is started on an antipsychotic/neuroleptic medication?

Making the client better able to participate in psychotherapy

The health care provider has discontinued clozapine for a client recovering from a psychotic episode. Which outcome would the nurse expect to be included in the nursing plan of care?

Monitor white blood cell (WBC) count weekly for at least 4 weeks.

Which assessment finding supports the diagnosis of neuroleptic malignant syndrome (NMS) in a client with schizophrenia being treated with haloperidol? (Select all that apply.) Muscle stiffness Sweating Tongue rolling Temperature 105.8°F (41°C) Arching of the trunk

Muscle stiffness Sweating Temperature 105.8°F (41°C)

A client with schizophrenia repeatedly says to the nurse, "No moley, jandu!" Which behavior is the client exhibiting?

Neologism

Which subtype of schizophrenia may have a good prognosis with treatment?

Paranoid

Which action addresses the potential fluid overload if a client with schizophrenia is receiving intravenous (IV) fluids after becoming dehydrated?

Perform auscultation of lungs.

Which medication is likely to be responsible for development of extrapyramidal symptoms? (Select all that apply.) Clozapine Olanzapine Perphanazine Fluphenazine Trifluoperazine

Perphanazine Fluphenazine Trifluoperazine

Which would be the nurse's priority when caring for a schizophrenic client exhibiting signs of impaired judgment, paranoia, and agitation?

Protecting other clients

Which action should the nurse implement when a client diagnosed with schizophrenia talks about being controlled by others?

React to the feeling tone of the client's delusion.

Which subtype of schizophrenia has a poor prognosis? (Select all that apply.) Residual Paranoid Catatonic Disorganized Undifferentiated

Residual Disorganized

Which response is most therapeutic when a nurse enters a room to administer an oral medication to an agitated and angry client with schizophrenia, paranoid type, and the client shouts, "Get out of here!"?

Say, "I'll be back in a few minutes so we can talk."

Which mental disorder is considered a thought process disorder?

Schizophrenia

An adult with the diagnosis of schizophrenia is admitted to the psychiatric hospital. The client is un-groomed, appears to be hearing voices, is withdrawn, and has not spoken to anyone for several days. Which intervention should the nurse implement during the first few hospital days?

Seek out the client frequently to spend short periods together.

Which basis would the primary health care provider use to prescribe neuroleptic drug to a client diagnosed with schizophrenia?

Side effects

When a disturbed client who has a history of using neologisms says to the nurse, "My lacket huss kelong mon," which response will the nurse use?

Telling the client that these words cannot be understood

Which type of hallucination is most commonly experienced?

Auditory

Which is the primary basis for the development of schizophrenia?

Biological perspective

For which diagnosis is the establishment of a psychiatric advance directive (PAD) beneficial? (Select all that apply) Bipolar disease Paranoid schizophrenia Illness anxiety disorder Obsessive-compulsive disorder Narcissistic personality disorder

Bipolar disease Paranoid schizophrenia

A nurse greets a client who has been experiencing auditory hallucinations and delusions of persecution by saying, "Good evening; how are you?" The client responds, "He doesn't feel well." Which phenomenon does this response represent?

Dissociation

Which response by the nurse is most therapeutic when a client on a behavioral health unit continually talks about delusional topics?

Encourage the client to focus on reality issues.

Which intervention would the nurse implement to decrease injection discomfort for a client prescribed paliperidone for schizophrenia? Apply eutectic mixture of local anesthetics (EMLA) cream after injection. Use the shortest needle that is appropriate Use the Z-track method for all irritation medications. Encourage the client to rest the muscle after the injection. Ask the client to assume a supine position with feet turned inward. Press down with the thumb over the injection site for 10 minutes to numb it.

Use the Z-track method for all irritation medications.

While watching TV in the dayroom a client who has demonstrated withdrawn, regressed behavior suddenly screams, bursts into tears, and runs from the room to the far end of the hallway. Which intervention by the nurse should be implemented?

Walk to the end of the hallway where the client is standing

What is pseudoparkinsonism?

a condition brought on commonly by an antipsychotic drug, characterized by resting tremor, bradykinesia and rigidity (due to the blockage of dopamine receptors)

A nurse is writing a plan of care in the medical record of a paranoid male client who has unjustifiably accused his wife of having many extramarital affairs. Which outcome statement is considered intermediate?

"The client will develop feelings of self-worth."

Which response by the nurse is best when a client with the diagnosis of paranoid schizophrenia continues to say, "They're trying to kill me. They all are"?

"You're having very frightening thoughts."

A client with bipolar I disorder, manic episode, is prescribed a regimen of an antipsychotic agent and lithium carbonate. Which action of the antipsychotic will the nurse explain as the rationale for this regimen?

Acts to calm the client while allowing time for the lithium to reach a therapeutic level

Which symptom is expected when caring for a client with the diagnosis of major depression? (Select all that apply) Apathy Insomnia without fatigue Mood swings with manic episodes Guilt feelings Sleep disturbances

Apathy Guilt feelings Sleep disturbances

Which condition is electroconvulsive therapy (ECT) primarily used to treat?

Clinical depression