Mental Health Nursing Psychosis
A 56-year-old man is admitted to the inpatient unit after family members report that he seems to be experiencing auditory hallucinations. The man has a history of schizophrenia and has had several previous admissions. Which statement indicates to the nurse that the client is experiencing auditory hallucinations?
Devil
A client is admitted to the acute care psychiatric unit with a diagnosis of panic disorder with agoraphobia. During the initial assessment phase, what should the nurse focus on?
Easing the ancxiety
client with the diagnosis of schizophrenia refuses to eat meals. Which nursing action is most beneficial for this client?
Having a staff member sit with the client in a quiet area during mealtimes
After assessing a client, the nurse suspects that the client has shift-work sleep disorder (SWSD). Which medication would be prescribed to the client?
Modafinil
A confused, hallucinating client says, "My arms are turning to stone." What is the most therapeutic response by the nurse?
it can be fightening
Which is a second-generation antidepressant drug?
Citalopram
Which drug most commonly causes extrapyramidal side effects (EPS)?
Haloperidol
A client is heard saying, "I like eggs, fried by Meg, served on a keg, kicked in the leg and don't want her to hoopanize them ever again." What should the nurse note in the client's record?
"Client demonstrates clang association and neologism speech patterns."
The nurse finds a client with schizophrenia lying under a bench in the hall. The client says, "God told me to lie here." What is the best response by the nurse?
"I didn't hear anyone talking; come with me to your room."
The nurse teaches the client about foods to avoid while on phenelzine therapy. Which response given by the client indicates the need for further education?
"I should avoid raisins in my diet."
A client tells the nurse, "The voices say I'll be safe only if I stay in this room, wear these clothes, and avoid stepping on the cracks between the floor tiles." What is the best initial response by the nurse?
"I understand that these voices are real to you, but I want you to know that I don't hear them."
While speaking with a client with schizophrenia, the nurse notes that the client keeps interjecting sentences that have nothing to do with the main thoughts being expressed. The client asks whether the nurse understands. What is the best response by the nurse?
"I'd like to understand what you're saying, but I'm having difficulty following you."
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 days. What should the nurse say when trying to help this client shower?
"I'll help you take your shower now."
One morning a client with the diagnosis of schizophrenia claims to be Joan of Arc about to be burned at the stake. What is the most therapeutic response by the nurse?
"It seems like the world is a pretty scary place for you."
A disturbed client says, "The voices are saying that I killed my husband." What is the best response by the nurse?
"You seem to be having very frightening thoughts right now."
After a week on the mental health unit, a client with the diagnosis of paranoid schizophrenia continues to say, "They're trying to kill me. They all are." What is the best response by the nurse?
"You're having very frightening thoughts."
The nurse observed seizures in a client who is taking lithium for cycles of mania. Which laboratory parameters may lead to this condition?
3 meq/L
What are the priority nursing interventions for a grieving client? Select all that apply.
Allowing the client to express feelings Respecting the feelings of the client and creating a comfortable environment
The nurse finds that a child has inattention, hyperactivity, and impulsivity upon assessment. Which medication would be beneficial for the child?
Atomoxetine
A client is found to have paranoid schizophrenia, and the healthcare provider prescribes a typical antipsychotic medication. The picture illustrates the client's physical status as observed by the nurse on the client's first visit to the community mental health clinic. What extrapyramidal side effect has developed?
Akathisia
A client who is taking haloperidol has developed tardive dyskinesia. Which therapy is beneficial for the client?
Administering benzodiazepines
When being admitted to a mental health facility, a young male adult tells the nurse that the voices he hears frighten him. The nurse knows that clients tend to hallucinate more vividly at what point in their routine?
After going to bed
A client is diagnosed with acute mania. The primary healthcare provider plans to prescribe lithium therapy to the client. After assessing the client's condition, the primary healthcare provider changes the therapy. Which client conditions would cause the provider to change course? Select all that apply.
All BUT Glaucoma
A client with an obsessive-compulsive disorder continually walks up and down the hall, touching every other chair. When unable to do this, the client becomes upset. What should the nurse do?
Allow the behavior to continue for a specified time, letting the client help set the time limits to be imposed
A client with schizophrenia who is being admitted to a psychiatric hospital for evaluation refuses to remove dirty clothing. What should the nurse do to best meet the client's needs?
Allow the client to undress when ready to help maintain identity.
A client is hospitalized with social anxiety disorder. The client has a history of exhibiting intense, irrational fear of being scrutinized by others. Which primary anxiolytic medications would be prescribed to the client? Select all that apply.
Alprazolam Clonazepam
A client with the diagnosis of schizophrenia who has been hospitalized on a mental health unit for 2 weeks is to be discharged home. The client is vacillating between being happy and sad about going home. What term best describes these conflicting emotions?
Ambivalence
A client is on antipsychotic therapy for schizophrenia. During a follow-up visit, the nurse suspects acute akathisia. Which symptoms in the client support the nurse's suspicion? Select all that apply.
Anxiety Agitation Restless movent
A nurse is preparing a teaching plan to educate a relative of a client with schizophrenia about the early signs of relapse. What signs should the nurse plan to include? Select all that apply.
Appearing disheveled Staying alone in the house Exhibiting indifference to family activities
A client is out of touch with reality, spending most of the time pacing the hall and responding to auditory hallucinations. The client does not perform the activities of daily living. What should the nurse plan to do?
Assist the client in meeting physical needs until they can be performed independently
A psychiatric nurse has been working with a client who is experiencing a relapse of psychotic symptoms. Command hallucinations are ruled out, and the content of the auditory messages has been determined. What should the nurse's next planned intervention be?
Assisting the client in recognizing hallucinations when they occur
A nurse is assigned to care for a college student who has been talking to unseen people and refusing to get out of bed, go to class, or participate in daily grooming activities. What is the nurse's initial intervention for this client?
Attempting to establish a meaningful relationship with the client
A client who is on haloperidol therapy has developed akathisia and acute dystonia. Which drugs would be used to manage extrapyramidal effects? Select all that apply.
Benztropine Trihexyphenidyl
Which food should be avoided by a client who is prescribed monoamine oxidase inhibitors (MAOIs)?
Bologna
Which client condition is contraindicated for prescribing clozapine?
Bone marrow depression
A nurse plans to establish a trusting relationship with a client who is using paranoid ideation. How should the nurse begin to accomplish this?
By being available on the unit but waiting for the client to approach
A nurse is caring for several clients with major thought disorders such as schizophrenia. They are all being treated with neuroleptic drugs. How do these drugs act in the body to promote mental health?
By blocking access to dopamine receptors at the postsynaptic receptor site
A client is admitted to the acute psychiatric unit of the local community hospital. The client is guarded and suspicious. After a thorough evaluation, a diagnosis of schizophrenia, paranoid type, is made. What initial approach should be used by the nurse assigned to establish a therapeutic one-on-one relationship with this client?
Casual and honest
A client describes his delusions in minute detail to the nurse. How should the nurse respond?
Changing the topic to reality-based events
Which toxic effect would the nurse find in a client who has overdosed on isocarboxazid?
Circulatory collapse
The nurse is assessing four clients in the postanesthesia care unit (PCU) who are on opioid treatment. Which client does the nurse expect will benefit from an immediate treatment with naloxone?
Client D
What is the best drug of choice for treating obsessive-compulsive disorder?
Clomipramine
Which statement is true regarding antipsychotic drugs?
Clozapine is more effective than other second-generation antipsychotics.
A man is admitted to the psychiatric unit after attempting suicide. The client's history reveals that his first child died of sudden infant death syndrome 2 years ago, that he has been unable to work since the death of the child, and that he has attempted suicide before. When talking with the nurse he says, "I hear my son telling me to come over to the other side." What should the nurse conclude that the client is experiencing?
Command hallucination
A pregnant client with a history of delusions, hallucinations, and suspiciousness tells the nurse she is fearful about the upcoming birth and the health of her baby. What is the best initial approach by the nurse?
Commending the client on her ability to express her concerns
What client behavior indicates to the nurse that a client with schizophrenia, undifferentiated type, is improving and that the client's plan of care can be updated?
Communicates with others in an organized manner
What is the priority nursing action for a client with delirium?
Creating...safety
Despite repeated nursing interventions to improve reality orientation, a client insists that he is the commander of an alien spaceship. What is the client experiencing?
Delusion
During a one-on-one interaction with a client with paranoid-type schizophrenia, the client says to the nurse, "I've figured out how foreign agents have infiltrated the news media. They want to shut me up before I spill the beans." How should the nurse describe this statement when documenting this client's response?
Delusions of persecution
Which condition is contraindicated for St. John's wort herbal therapy?
Dementia
One morning a client tells the nurse, "My legs are turning to rubber because I have an incurable disease called schizophrenia." What is this statement an example of?
Depersonalization
A nurse is caring for a client with the diagnosis of schizophrenia. What is a common problem for clients with this diagnosis?
Disordered thinking
A client is experiencing hallucinations. What therapeutic intervention should the nurse plan to help the client cope with the hallucinations
Distracting the client's attention by providing a competing stimulus that is stronger than the hallucinations
Which second-generation antidepressant can worsen uncontrolled angle closure glaucoma?
Duloxetine
Which medications are used to treat generalized anxiety disorder (GAD)? Select all that apply.
Duloxetine Venlafaxine Escitalopram
Which drugs may cause an increase in the serum clozapine level? Select all that apply.
Erythromycin Ketoconazole
The nurse cares for a client with bipolar disorder who is receiving drug therapy. The laboratory report reveals that the client's serum sodium level is 132 mEq/L (132 mmol/L). Which drug might have led to this condition?
Fluoxetine
The mother of a client reports, "My son is afraid of every small thing and has a fear of dying." Upon assessment, the nurse finds palpitations, racing heartbeat, and sweating. Which first-line medications would be beneficial for the client? Select all that apply.
Fluoxetine Sertraline
A nurse is caring for a client who uses ritualistic behavior. What common antiobsessional medication does the nurse anticipate will be prescribed?
Fluvoxamine
The primary healthcare provider informs the registered nurse that the client must be monitored on a regular basis because he or she is prescribed haloperidol. Which client conditions would warrant these instructions? Select all that apply.
Glaucoma Adynamic ileus Prostatic hypertrophy
A nurse is planning activities for a withdrawn client who is hallucinating. Which activity will be most therapeutic for the client?
Going for a walk with the nurse
A client on the psychiatric unit tells the nurse, "I'm a movie star, and the other clients are my audience." What is an appropriate conclusion for the nurse to document about what the client is experiencing?
Grandeur
As a nurse enters a room and approaches a client who has schizophrenia, the client shouts, "Get out of here before I hit you! Go away!" What does the nurse conclude provoked the client's aggressive behavior?
He felt confined when the nurse walked into the room.
What should a nurse do when caring for a client whose behavior is characterized by pathologic suspicion?
Help the client feel accepted by the staff on the unit.
In preparation for medication administration, the nurse is reviewing the results of diagnostic laboratory tests on a newly admitted client. In light of this information, what is the initial nursing intervention?
Holding the morning dose of clozapine
The nurse suspects serotonin syndrome in a client prescribed second-generation antidepressants for depression. Which assessment findings observed by the nurse would be beneficial in diagnosing the severity of the syndrome? Select all that apply.
Hyperthermia Rhabdomy
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. What is the most appropriate conclusion to make about what the client was experiencing?
Illusion
A client and a nurse are standing next to each other in the mental health clinic when the client gets down on hands and knees and says, "I'm a table." What is the best response by the nurse?
LOL Hold out a hand to help the client up while saying, "You're not a table; you're a person."
Which drug may lead to bruxism?
Levomilnacipran
When a newly admitted client with paranoid ideation tells the nurse about people coming through the doors to commit murder, what should the nurse do?
Listen to what the client is saying.
A client who has been admitted with a diagnosis of schizophrenia says to the nurse, "Yes, it's March. March is Little Women. That's literal, you know." What do these statements illustrate?
Loosening of associations
Which antipsychotic drugs have the higher risk of causing tardive dyskinesia? Select all that apply.
Loxapine Haloperidol
What is most important for the nurse to do when caring for a client who is experiencing a paranoid delusion?
Maintain eye contact when talking with the client
A client with schizophrenia is started on an antipsychotic/neuroleptic medication. The nurse explains to a family member that this drug primarily is used to achieve what purpose?
Make the client more receptive to psychotherapy
Which medication is the first choice drug for the treatment of attention deficit hyperactivity disorder (ADHD)?
Methylphenidate
Which adverse effect is least likely to occur in a client who is prescribed clozapine?
Myocarditis Clozapine is a second-generation antipsychotic drug. Myocarditis is a very rare side effect caused by clozapine. Seizures, sedation, and akathisia are common side effects of clozapine.
A client with schizophrenia is speaking made-up words that have no meaning to other people. What term should the nurse use to document these verbalizations?
Neologisms
The primary healthcare provider prescribes a neuroleptic drug to a client diagnosed with schizophrenia. On what basis would the primary healthcare provider choose the drug?
Side effects
A male client with a history of schizophrenia comes to the emergency department, accompanied by his wife. What is the emergency department nurse's priority intervention?
Observing and evaluating his behavior
A nurse is caring for a male client who was admitted to the mental health unit with the diagnosis of schizophrenia. The client is hostile and experiencing auditory hallucinations and states that the voices are saying that they are going to poison him because he is bad. What type of schizophrenic behavior does the nurse identify?
Paranoid
A client on antidepressant therapy develops hyponatremia. Which drug may be responsible for the client's electrolyte imbalance?
Paroxetine
A psychotic male client is admitted to the hospital for evaluation. While obtaining the history, the nurse asks why he was brought to the hospital by his parents. The client states, "They lied about me. They said I murdered my mother. You killed her. She died before I was born." What does the nurse recognize that the client is experiencing?
Persecutory delusions
Which condition contraindicates the use of ginseng herbal therapy?
Preggo
The nurse is caring for a client who is using paranoid ideation. When planning care, what should the nurse remember the importance of?
Providing
A nurse is caring for a client with the diagnosis of schizophrenia, paranoid type. What should the nurse plan for the client's initial care?
Providing a nonthreatening environment
The primary healthcare provider prescribes an atypical antipsychotic drug to a client and asks the nurse to set up an appointment for the client to see an ophthalmologist. Which drug was prescribed to the client?
Quetiapine
A nurse is assessing a client with the diagnosis of schizophrenia, undifferentiated type. What defense mechanisms should the nurse anticipate that this client might use?
Regression
What defense mechanism should the nurse anticipate that a client with the diagnosis of schizophrenia, undifferentiated type, will most often exhibit?
Regression
A pediatric client with a history of chickenpox is undergoing treatment for mental illness with psychotherapeutic drugs. Which is the expected adverse effect of the psychotherapeutic drug in the pediatric client?
Reye's syndrome
During the admission procedure a client appears to be responding to voices. The client cries out at intervals, "No, no! I didn't kill him! You know the truth—tell that police officer! Please help me!" What is the most appropriate response by the nurse?
Saying, "I want to help you. I realize that you must be very frightened."
The nurse is caring for a client with chronic pain who is on opioid treatment. The client has constipation, nausea, vomiting, level 3 sedation, respiratory rate of 8 breaths per minute, and pruritus. Which conditions of the client should the nurse consider as highest priority? Select all that apply.
Sedation Respiratory rate
Which antidepressant drug is a selective monoamine oxidase-B inhibitor?
Selegiline
Which drug would the nurse administer transdermally to treat a client with major depression?
Selegine
Which drugs are used as the first-line treatment for posttraumatic stress disorder (PTSD)? Select all that apply.
Sertraline Paroxetine
At mealtime a client with schizophrenia moves to the counter to choose food but is unable to decide what to do next. How can the nurse best assist the client?
Speaking in simple declarative statements
On the afternoon of admission to a psychiatric unit, an adolescent boy with the diagnosis of schizophrenia exposes his genitals to a female nurse. What should the nurse's immediate therapeutic response be?
Stating that this behavior is unacceptable
A client with the diagnosis of schizophrenia refuses to get out of bed and becomes upset. What is the nurse's initial therapeutic response? <p>A client with the diagnosis of schizophrenia refuses to get out of bed and becomes upset. What is the nurse’s <b>initial </b>therapeutic response?</p>
Staying at the bedside until the client calms down
A client with the diagnosis of schizophrenia, paranoid type, is admitted to the hospital. The client says to the nurse, "I know they're spying on me in here, too. I'm not safe anywhere!" What is the most therapeutic response by the nurse?
You don't feel safe anywhere, not even in the hospital?"
Which client characteristic is an initial concern for the nurse when caring for a client with the diagnosis of paranoid schizophrenia?
Suspicious feelings
A client has been taking 3 mg of risperidone twice a day for the past 8 days. At the follow-up appointment, the client reports tremors, shortness of breath, a fever, and sweating. What will the nurse do?
Take the client's vital signs and arrange for immediate transfer to a hospital.
A nurse is managing the care of a client with recently diagnosed schizophrenia. Effective therapeutic communication will directly affect which client-focused outcomes? Select all that apply.
The client will effectively express emotional and physical needs. he client will demonstrate an understanding of the mental health disorder. The client will recognize the issues most important to managing this disorder.
A client tells the nurse, "I'm a terrible, evil person. The voices are telling me that God needs to punish me." What is the most therapeutic initial response by the nurse?
Tell me what you're thinking about yourself."
A client who has been hallucinating suddenly rises and shouts, "Stop saying that. Who do you think you are?" What is the most therapeutic response by the nurse?
Telling the client that the voices are not heard by others, then offering to listen to music together
Which drugs are considered typical antipsychotics? Select all that apply.
Thioridazine Chlorpromazine
The nurse advises the client to refrain from skin contact of the prescribed liquid formulation. Which antipsychotic drug is prescribed to the client?
Thorazine
In the care of a withdrawn, reclusive psychotic client, the priority goal is for the client to develop what?
Trust
A client has just been admitted to the psychiatric unit on involuntary admission status. During the admission assessment the client tells the nurse, "I am the second son of God and need to say a prayer." What is the best response by the nurse?
Waiting until the client finishes the prayer and then completing the assessment
While watching television 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. What is the most therapeutic intervention by the nurse?
Walking to the end of the hallway where the client is standing
A client in the psychiatric hospital is attempting to communicate by stating, "Sky, flower, angry, green, opposite, blanket." The nurse recognizes what term as describing this type of communication?
Word Salad
The nurse cares for a client who has schizophrenia and is taking chlorpromazine. The nurse instructs the family members to inform the nurse if any adverse effects develop. Which side effects are considered late extrapyramidal side effects?
Worm like tongue
After 2 days on the unit a client with the diagnosis of schizophrenia refuses to take a shower. What is the most appropriate intervention by the nurse?
gentle basin hands face
A client with schizophrenia is given an antipsychotic drug. The nurse recalls all the extrapyramidal effects associated with this type of medication and anticipates that the drug will be discontinued if which occurs?
ardive dyskinesia
A nurse is caring for a client with the diagnosis of schizophrenia. What should the nurse plan to do to increase the self-esteem of this client?
eward healthy behaviors
A delusional client verbalizes the belief that others are out to cause the client harm. A nurse notes the client's worsening pacing and agitation. What is the best nursing intervention?
oving the client to a quiet place on the unit
