NCLEX Q's: Schizophrenia Spectrum and Other Psychotic Disorders

A client diagnosed with a thought disorder is experiencing clang associations. Which nursing diagnosis reflects this client's problem? 1. Impaired verbal communication. 2. Risk for violence. 3. Ineffective health maintenance. 4. Disturbed sensory perception.

1 --- 2, 3, 4 (no indication)

Which client is most likely to benefit from group therapy? 1. A client diagnosed with schizophrenia being followed up in an out-patient clinic. 2. A client diagnosed with schizophrenia newly admitted to an in-patient unit for stabilization. 3. A client experiencing an exacerbation of the signs and symptoms of schizophrenia. 4. A client diagnosed with schizophrenia who is not adherent with antipsychotic medications.

1 --- 2 (inpatient = lower level of functioning) 3 (less stimulating environment would be more beneficial) 4 (w/o meds group tx would not be as beneficial)

A client is in the active phase of schizophrenia and is experiencing paranoid thinking. Which nursing intervention would aid in facilitating other interventions? 1. Assign consistent staff members. 2. Convey acceptance of the client's delusional belief. 3. Help the client understand that anxiety causes hallucinations. 4. Encourage participation in group activities.

1 (consistency helps build trust) --- 2 (should convey acceptance of the client and the need for false belief not the belief itself) 3 (hallucinations can cause anxiety not the other way) 4 (group activities can be misinterpreted and aren't appropriate at this time)

A client newly admitted to an in-patient psychiatric unit is scanning the environment continuously. Which nursing intervention is most appropriate to address this client's behavior? 1. Offer self to build a therapeutic relationship with the client. 2. Assist the client in formulating a plan of action for discharge. 3. Involve the family in discussions about dealing with the client's behaviors. 4. Reinforce the need for medication adherence on discharge.

1 (displaying paranoid thinking so build trust) --- 2 (new admit, not ready for discharge planning) 3 (trust first then assess client's acceptance of family involvement) 4 (relationship should be built first)

A student nurse is assessing a 20 year-old client who is experiencing auditory hallucinations. The student states, "I believe the client has schizophrenia." Which of the following instructor responses is the most appropriate? Select all that apply. 1. "How long has the client experienced these symptoms?" 2. "Has the client taken any drug or medication that could cause these symptoms?" 3. "It is not within your scope of practice to assess for a medical diagnosis." 4. "Does this client have any mood problems?" 5. "What kind of relationships has this client established?"

1 (duration important; present for 1-6 mo) 2 (substance use may rule out dx of schizophrenia) 4 (schizoaffective, depressive w/ psychotic features, bipolar must be ruled out) 5 (interpersonal relationships are impacted)

The nurse is teaching a client diagnosed with schizophreniform disorder about what may affect a good prognosis. Which of the following features should the nurse include? Select all that apply. 1. Confusion and perplexity at the height of the psychotic episode. 2. Good premorbid social and occupational functioning. 3. Absence of blunted or flat affect. 4. Predominance of negative symptoms. 5. Onset of psychotic symptoms within 4 weeks of noticeable behavioral change.

1 (element of insight that is absent in more severe cases) 2 3 5 --- 4 (if negative signs or predominant, dx unlikely)

Which outcome should the nurse expect from a client diagnosed with schizophrenia who is hearing and seeing things others do not hear and see? 1. The client will recognize distortions of reality by discharge. 2. The client will demonstrate the ability to trust by day 2. 3. The client will recognize delusional thinking by day 3. 4. The client will experience no auditory hallucinations by discharge.

1 (hallucinations) --- 2 (unrealistic) 3 (not experiencing delusions) 4 (unrealistic; can help decrease but not completely disappear)

Which of the following clients have the greatest chances of positive prognoses after being diagnosed with schizophrenia? Select all that apply. 1. A client diagnosed at age 35. 2. A male client experiencing a gradual onset of signs and symptoms. 3. A female client whose signs and symptoms began after a rape. 4. A client who has a family history of schizophrenia. 5. A client who has a family history of a mood disorder diagnosis.

1 (later age associate w/ + prognosis) 3 (abrupt onset and female associated w/ + prognosis) 5 (family history associated w/ + prognosis) --- 2 (slow and male associated with poor prognosis) 4 (family history associated with poor prognosis)

The nurse is assessing a client diagnosed with schizophrenia with catatonic features. Which of the following symptoms should the nurse expect the client to exhibit? Select all that apply. 1. Catalepsy. 2. Waxy flexibility. 3. Pressured speech. 4. Posturing. 5. Stereotypye

1 (passive induction of a posture held against gravity) 2 (passively yields all movable parts of body to any efforts made at placing them in certain positions) 4 (spontaneous and active of a posture against gravity) 5 (repetitive, abnormally frequent, non-goal directed movement) --- 3 (mutism not pressured speech)

A client, diagnosed with schizophrenia, is experiencing social withdrawal, flat affect, and impaired role functioning. To distinguish whether this client is in the prodromal or residual phase of schizophrenia, what question would the nurse ask the family? 1. "Have these symptoms followed an active period of schizophrenic behaviors?" 2. "How long have these symptoms been occurring?" 3. "Has the client had a change in mood?" 4. "Has the client been diagnosed with any developmental disorders?"

1 (residual follows prodromal) --- 2 (duration is helpful but doesn't help distinguish) 3 (important but doesn't help distinguish) 4 (but be made before diagnosis and doesn't help distinguish)

A homeless client, diagnosed with schizophrenia, is seen in the mental health clinic complaining of insects infesting arms and legs. Which intervention should the nurse implement first? 1. Check the client for body lice. 2. Present reality regarding somatic delusions. 3. Explain the origin of persecutory delusions. 4. Refer for in-patient hospitalization because of substance-induced psychosis.

1 (rule out physical cause first) --- 2 (after ruling out physical) 3 (experiencing somatic not persecutory) 4 (no info indicates)

A nurse is assessing a client with a long history of being a loner and having few social relationships. This client's father has been diagnosed with schizophrenia. The nurse would suspect that this client is in what phase of the development of schizophrenia? 1. Phase I—premorbid phase. 2. Phase II—prodromal phase. 3. Phase III—schizophrenia. 4. Phase IV—residual phase.

1 (social maladjustment, withdrawal, irritability) --- 2 (social withdrawal, impairment, eccentric behaviors, neglect, lack of energy) 3 (psychotic symptoms present) 4 (symptoms of residual similar to prodromal)

The nurse is assessing a client diagnosed with schizophrenia. The client states, "We wanted to take the bus, but the airport took all the traffic." Which charting entry accurately documents this symptom? 1. "The client is experiencing associative looseness." 2. "The client is attempting to communicate by the use of word salad." 3. "The client is experiencing delusional thinking." 4. "The client is experiencing an illusion involving planes."

1 (thinking characterized by speech in which ideas shift from one unrelated subject to another) --- 2 (group of words strung together in random fashion) 3 (false personal beliefs) 4 (misperceptions of real external stimuli)

Schizophrenia is identified in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), as a spectrum disorder based on the severity of symptoms. Which of the following accurately describes this diagnostic category? Select all that apply. 1. Degree of severity of the schizophrenia spectrum is determined by the number of psychotic symptoms. 2. Schizotypal personality disorder initiates the schizophrenia spectrum. 3. Symptoms within the schizophrenia spectrum are directly attributable to toxins. 4. Degree of severity of the schizophrenia spectrum is determined by the duration of psychotic symptoms. 5. Schizophrenia spectrum disorders can carry the additional specification of with catatonic features.

1, 2, 4, 5 --- 3 (symptoms shouldn't be attributable to toxins)

An instructor is teaching students about psychiatric medications. Which of the following antipsychotic medications need to be given with food? Select all that apply. 1. Ziprasidone (Geodon). 2. Vilazodone (Viibryd). 3. Lurasidone (Latuda). 4. Aripiprazole (Abilify). 5. Asenapine (Saphris).

1, 3 --- 2 (antidepressant) 4 (not needed with food) 5 (under the tongue)

Which of the following medications would be given to a client, in an outpatient setting, diagnosed with schizophrenia experiencing nonadherence? Select all that apply. 1. Olanzapine IM (Zyprexa Relprevv). 2. Ziprasidone IM (Geodon IM). 3. Haloperidol Lactate (Haldol Lactate). 4. Aripiprazole IM (Abilify Maintena). 5. Paliperidone IM (Invega Trinza).

1, 4, 5 --- 2 (short acting antipsychotic used in acute not outpatient) 3 (short acting antipsychotic used In acute not outpatient)

When one fraternal twin has been diagnosed with schizophrenia, the other twin has approximately a _____ % chance of developing the disease.

15%

A client is prescribed risperidone (Risperdal) 4 mg bid. After the client is caught cheeking medications, liquid medication is prescribed. The label reads 0.5 mg/mL. How many milliliters would be administered daily? _____ mL.

16 mL --- 4 mg x 1 mL/0.5 mg = 8 mL 8 mL x 2 doses (BID) = 16 mL

A client admitted to an in-patient setting has not been adherent with antipsychotic medications prescribed for schizophrenia. Which outcome related to this client's problem should the nurse expect the client to achieve? 1. The client will maintain anxiety at a reasonable level by day 2. 2. The client will take antipsychotic medications by discharge. 3. The client will communicate to staff any paranoid thoughts by day 3. 4. The client will take responsibility for self-care by day 4.

2 --- 1 (anxiety not in problem) 3 (not related to non-adherence) 4 (more appropriate if having self-care deficit)

The nurse is educating the family of a client diagnosed with schizophrenia about the importance of medication adherence. Which statement indicates that learning has occurred? 1. "After stabilization, the relapse rate is high, even if antipsychotic medications are taken regularly." 2. "My brother will have only about a 30% chance of relapse if he takes his medications consistently." 3. "Because the disease is multifaceted, taking antipsychotic medications has little effect on relapse rates." 4. "Because schizophrenia is a chronic disease, taking antipsychotic medications has little effect on relapse rates."

2 --- 1 (w/o meds relapse is 70-80%; w/ meds it's 30%) 3 (taking meds can reduce the relapse rate) 4 (is chronic but meds can reduce relapse rate)

Which intervention used for clients diagnosed with schizophrenia is a behavioral therapy approach? 1. Offer opportunities for learning about psychotropic medications. 2. Attach consequences to adaptive and maladaptive behaviors. 3. Establish trust within a relationship. 4. Encourage discussions of feelings related to delusions.

2 --- 1 (cognitive) 3 (interpersonal) 4 (intrapersonal)

Although symptoms of schizophrenia occur at various times in the life span, what client would more likely be diagnosed? 1. A 10 year-old girl. 2. A 20 year-old man. 3. A 50 year-old woman. 4. A 65 year-old man.

2 ( symptoms appear in late adolescence and early adulthood) --- 1 (children not typically dx) 3 (can occur in middle or late adulthood, but not typical) 4 (can occur in middle or late adulthood, but not typical)

A client recently prescribed fluphenazine (Prolixin) complains to the nurse of severe muscle spasms. On examination, heart rate is 110, blood pressure is 160/92 mm Hg, and temperature is 101.5°F. Which nursing intervention takes priority? 1. Check the chart for a prn order of benztropine mesylate (Cogentin) because of increased extrapyramidal symptoms. 2. Hold the next dose of fluphenazine and call the physician immediately to report the findings. 3. Schedule an examination with the client's physician to evaluate cardiovascular function. 4. Ask the client about any recreational drug use, and ask the physician to order a drug screen.

2 (NMS symptoms) --- 1 (experiencing NMS not EPS symptoms) 3 (d/t NMS not cardiac problems) 4 (drugs can cause symptoms but understanding linking between NMS and neuroleptics is important)

A client diagnosed with schizophrenia who is experiencing paranoid thinking tells the nurse about three previous suicide attempts. Which nursing diagnosis would take priority and reflect this client's problem? 1. Disturbed thought processes. 2. Risk for suicide. 3. Violence: directed toward others. 4. Risk for altered sensory perception.

2 (SAFETY)

The nurse states, "It's time for lunch." A client diagnosed with schizophrenia responds, "It's time for lunch, lunch, lunch." Which type of communication process is the client using, and what is the underlying reason for its use? 1. Echopraxia, which is an attempt to identify with the person speaking. 2. Echolalia, which is an attempt to acquire a sense of self and identity. 3. Unconscious identification to reinforce weak ego boundaries. 4. Depersonalization to stabilize self-identity.

2 (attempt to identify with the person speaking) --- 1 (imitate movements made by others) 3 (ego defense mechanism; imitating actions or physical characteristics) 4 (experience feelings of unreality; person observes themself at a distance)

The nurse is performing an admission assessment on a client diagnosed with schizophrenia who is experiencing paranoid thinking. To receive the most accurate assessment information, which should the nurse consider? 1. This client will be able to make a significant contribution to history data collection. 2. Data will need to be gained by reviewing old records and talking with family. 3. This client's assessment will be easy because of the consistent nature of the symptoms. 4. The nurse should use a very friendly approach to put the client at ease.

2 (background info must be gathered from multiple sources) --- 1 (not able to do if experiencing paranoid thinking) 3 (complex not simple process b/c of thought/communication deficits) 4 (overly friendly might be interpreted as an attempt at manipulation)

A client's family is having a difficult time accepting the client's diagnosis of schizophrenia, and this has led to family conflict. Which nursing diagnosis reflects this problem? 1. Impaired home maintenance. 2. Interrupted family processes. 3. Social isolation. 4. Disturbed thought processes.

2 (change in family relationships or functioning or both)

From a biochemical influence perspective, which accurately describes the etiology of schizophrenia? 1. Adopted children with nonschizophrenic parents, raised by parents diagnosed with schizophrenia, have a higher incidence of this disease. 2. An excess of dopamine-dependent neuronal activity occurs in the brain. 3. A higher incidence of schizophrenia occurs after there is prenatal exposure of the mother to influenza. 4. Poor parent-child interaction and dysfunctional family systems occur.

2 (dopamine hypothesis) --- 1 (no research shows they suffer more often than general population) 3 (physiological not biological influence) 4 (may precipitate symptoms but doesn't cause)

A client with a nursing diagnosis of disturbed thought processes has an expected outcome of recognizing delusional thinking. Which intervention would the nurse first implement to address this problem? 1. Reinforce and focus on reality. 2. Appreciate that the client has experienced disturbing delusional thinking. 3. Indicate that the nurse does not share the belief. 4. Present logical information to refute the delusional thinking.

2 (first step is empathy to build trust) --- 1 (important but not priority) 3 (important but not initial intervention) 4 (using logic can impede trust)

A nurse is working with a client diagnosed with schizoid personality disorder. What symptom of this diagnosis should the nurse expect to assess, and at what risk is this client for acquiring schizophrenia? 1. Delusions and hallucinations—high risk. 2. Limited range of emotional experience and expression—high risk. 3. Indifferent to social relationships—low risk. 4. Loner who appears cold and aloof—low risk.

2 (indifferent to social relationships; don't enjoy close relationships, appear cold/aloof; not all w/ schizoid progress to schizophrenia) --- 1 (don't typically have hallucinations) 2 (puts them at high not low risk) 3 (puts them at high not low risk)

The nurse is educating the family members of a client diagnosed with schizophrenia about the effects of psychotherapy. Which statement should be included in the teaching plan? 1. "Psychotherapy is a short-term intervention that is usually successful." 2. "Much patience is required during psychotherapy because clients often relapse." 3. "Major changes in client symptoms can be attributed to immediate psychotherapy." 4. "Independent functioning can be gained by immediate psychotherapy."

2 (may continue for years) --- 1 (long-term not short-term) 3 (behavior changes may not occur immediately) 4 (no guarantee of independent functioning)

A client diagnosed with schizoid personality disorder asks the nurse in the mental health clinic, "Does this mean I will get schizophrenia?" What nursing response would be most appropriate? 1. "Does that possibility upset you?" 2. "Not all clients diagnosed with schizoid personality disorders progress to schizophrenia." 3. "Few clients with a diagnosis of schizophrenia show evidence of early personality changes." 4. "What do you know about schizophrenia?"

2 (most individuals w/ schizophrenia show evidence of having schizoid in premorbid state) --- 1 (doesn't address concern) 3 (most not few) 4 (important to assess knowledge but doesn't address concern)

What is required for effective treatment of schizophrenia? 1. Concentration on pharmacotherapy alone to alter imbalances in affected neurotransmitters. 2. Multidisciplinary, comprehensive efforts, which include pharmacotherapy and psychosocial care. 3. Emphasis on social and living skills training to help the client fit into society. 4. Group and family therapy to increase socialization skills.

2 (social & living skills, rehab, family tx) --- 1 (no single tx) 3 (one aspect of tx) 4 (one aspect of tx)

The nurse reports that a client diagnosed with a schizophrenia spectrum disorder is experiencing religiosity. Which client statement would confirm this finding? 1. "I see Jesus in my bathroom." 2. "I read the Bible every hour so that I will know what to do next." 3. "I have no heart. I'm dead and in heaven today." 4. "I can't read my Bible because the CIA has poisoned the pages."

2 (use religion in an attempt to provide rational meaning or structure to behavior) --- 1 (visual hallucination) 3 (nihilistic delusion) 4 (paranoid delusion)

Which of the following oral antipsychotic medications could be administered on an inpatient psychiatric unit to prevent a client from cheeking, or hiding medication in the mouth? Select all that apply. 1. Mirtazapine (Remeron SolTab). 2. Olanzapine (Zyprexa Zydis). 3. Paliperidone (Invega Sustenna). 4. Aripiprazole (Abilify Discmelt). 5. Asenapine (Saphris).

2, 4, 5 (dissolve rapidly in saliva) --- 1 (antidepressant) 3 (long acting injection)

A client is prescribed clozapine (Clozaril) 12.5 mg qam and 50 mg qhs. Clozapine is available in 25-mg tablets. How many tablets would be administered daily? _____ tablets.

2.5 tablets --- 12.5 mg x 1 tablet/25 mg = 0.5 tab 50 mg x 1 tab/25 mg = 2 tab 0.5 + 2 = 2.5 tablets/day

Lithium carbonate (Lithium) is to mania as clozapine (Clozaril) is to: 1. Anxiety. 2. Depression. 3. Psychosis. 4. Akathisia.

3 --- 1 (benzos and SSRIs) 2 (MAOIs, TCA, SSRIs) 4 (EPS not med)

Which outcome should the nurse expect from a client with a nursing diagnosis of social isolation? 1. The client will recognize distortions of reality by day 4. 2. The client will use appropriate verbal communication when interacting by day 3. 3. The client will actively participate in unit activities by discharge. 4. The client will rate anxiety as 5/10 by discharge.

3 --- 1 (disturbed thought process) 2 (impaired verbal communication) 4 (anxiety)

A woman is prescribed risperidone (Risperdal) 1 mg bid. At her 3-month follow-up, the client states, "I knew it was a possible side effect, but I can't believe I am not getting my period anymore." Which is a priority teaching need? 1. "Sometimes amenorrhea is a temporary side effect of medications and should resolve itself." 2. "I am sure this was very scary for you. How long has it been since your last menstrual cycle?" 3. "Although your menstrual cycles have stopped, there is still a potential for you to become pregnant." 4. "Maybe the amenorrhea is not due to your medication. Have your menstrual cycles been regular in the past?"

3 --- 1 (resolves when PT is off medicine) 2 (assessment not teaching) 4 (assessment not teaching)

A client has the nursing diagnosis of impaired home maintenance R/T regression. Which behavior confirms this diagnosis? 1. The client fails to take antipsychotic medications. 2. The client states, "I haven't bathed in a week." 3. The client lives in an unsafe and unclean environment. 4. The client states, "You can't draw my blood without crayons."

3 (AEB unsafe, unclean, disorderly home) --- 1 (ineffective health maintenance R/T non-adherence) 2 (self-care deficit) 4 (altered thought process)

The nurse documents that a client diagnosed with schizophrenia is expressing a flat affect. What is an example of this symptom? 1. The client laughs when told of the death of his or her mother. 2. The client sits alone and does not interact with others. 3. The client exhibits no emotional expression. 4. The client experiences no emotional feelings.

3 (devoid of emotional tone) --- 1 (inappropriate affect) 2 (social isolation) 4 (w/ flat affect you can still experience feelings)

A client states to the nurse, "I see headless people walking down the hall at night." Which nursing response is appropriate? 1. "What makes you think there are headless people here?" 2. "Let's think about this. A headless person would not be able to walk down the hall." 3. "It must be frightening. I realize this is real to you, but I see no headless people." 4. "I don't see those people you are talking about."

3 (empathizing) --- 1 (challenging can lead to defensive behaviors) 2 (logic and challenging is not helpful) 4 (implied validation of hallucination)

A client is exhibiting sedation, auditory hallucinations, dystonia, and grandiosity. The client is prescribed haloperidol (Haldol) 5 mg tid and trihexyphenidyl (Artane) 4 mg bid. Which statement about these medications is accurate? 1. Artane would assist the client with sedation. 2. Artane would assist the client with auditory hallucinations. 3. Haldol would assist the client in decreasing grandiosity. 4. Haldol would assist the client with dystonia.

3 (haldol antipyschotic that decreases grandiosity) --- 1 (artane is an anticholinergic to counteract EPS; sedation is SE of haldol) 2 (not used to treat hallucinations) 4 (causes dystonia; artane counteracts)

A client on an in-patient psychiatric unit refuses to take medications because "The pill has a special code written on it that will make it poisonous." What kind of delusion is this client experiencing? 1. An erotomanic delusion. 2. A grandiose delusion. 3. A persecutory delusion. 4. A somatic delusion.

3 (individuals believe they are being malevolently treated in some away) --- 1 (individuals believe that someone of higher status is in love with them) 2 (individual has irrational idea regarding self-worth) 4 (individuals believe they have some sort of physical defect)

A client taking olanzapine (Zyprexa) has a nursing diagnosis of altered sensory perception R/T command hallucinations. Which outcome would be appropriate for this client's problem? 1. The client will verbalize feelings related to depression and suicidal ideations. 2. The client will limit caloric intake because of the side effect of weight gain. 3. The client will notify staff members of bothersome hallucinations. 4. The client will tell staff members if experiencing thoughts of self-harm.

3 (r/t sensory perception; helps staff intervene if commanding) --- 1 (at risk of suicide) 2 (weight gain is SE but not related to nursing diagnosis) 4 (risk for violence: self directed)

A client diagnosed with schizophrenia takes clozapine (Clozaril) 200 mg qd. Lab results reveal RBC 4.7 million/mcL, ANC 800/mcL, and TSH 1.3 mIU/L. Which of the following would the nurse expect the physician to order? 1. "Levothyroxine sodium (Synthroid) 150 mcg qd." 2. "Ferrous sulfate (Feosol) 100 mg tid." 3. "Discontinue clozapine." 4. "Discontinue clozapine and start levothyroxine sodium 150 mcg qd."

3 (risk for neutropenia on clozapine; normal ANC > 1500 --- 1 (used for TSH; TSH levels are normal (0.4-4)) 2 (RBC are within normal ranges 4.6-6) 4 (d/c clozapine but TSH are normal and levo is not needed)

The nurse is discussing the side effects experienced by a female client taking antipsychotic medications. The client states, "I haven't had a period in 4 months." Which client teaching should the nurse include in the plan of care? 1. Antipsychotic medications can cause a decreased libido. 2. Antipsychotic medications can interfere with the effectiveness of birth control. 3. Antipsychotic medications can cause amenorrhea, but ovulation still occurs. 4. Antipsychotic medications can decrease red blood cells, leading to amenorrhea.

3 (risk for pregnancy) --- 1 (can cause but not relative to teaching) 2 (no evidence) 4 (no evidence)

The children's saying "Step on a crack and you break your mother's back" is an example of which type of thinking? 1. Concrete thinking. 2. Thinking using neologisms. 3. Magical thinking. 4. Thinking using clang associations.

3 (thoughts/behaviors have control over specific situations or people) --- 1 (literal interpretation of environment) 2 (invention of new words) 4 (choice of words governed by sound)

A client is brought to the emergency department after being found wandering the streets and talking to unseen others. Which situation is further evidence of a diagnosis of schizophrenia for this client? 1. The client exhibits a developmental disorder, such as autism spectrum disorder. 2. The client has a medical condition that could contribute to the symptoms. 3. The client experiences manic or depressive signs and symptoms. 4. The client's signs and symptoms last for 6 months.

4

The nurse documents that a client diagnosed with schizophrenia is experiencing anticholinergic side effects from long-term use of thioridazine (Mellaril). Which symptoms has the nurse noted? 1. Akinesia, dystonia, and pseudoparkinsonism. 2. Muscle rigidity, hyperpyrexia, and tachycardia. 3. Hyperglycemia and diabetes. 4. Dry mouth, constipation, and urinary retention.

4 --- 1 (EPS side effects) 2 (NMS side effects) 3 (do happen but not anticholinergic SE)

A client has an order for "ziprasidone (Geodon) 20 mg IM q4h prn for agitation with a maximum daily dose of 40 mg/day." Administration times are documented in the medication record. Which times indicate safe medication administration? 1. "0800 and 1100". 2. "1200, 1700, and 2100". 3. "0900, 1200, and 2100". 4. "1300 and 1700".

4 --- 1300 and 1700 are 4 hours apart = q4h

Which interaction is most reflective of an appropriate psychotherapeutic approach when interacting with a client diagnosed with schizophrenia? 1. The nurse should exhibit exaggerated warmth to counteract client loneliness. 2. The nurse should profess friendship to decrease social isolation. 3. The nurse should attempt closeness with the client to decrease suspiciousness. 4. The nurse should establish a relationship by respecting the client's dignity.

4 --- 1 (can be met with confusion and suspicion) 2 (maintain professional relationship) 3 (can be met with aggression, anxiety, regression)

In the United States, which diagnosis has the lowest percentage of occurrence? 1. Major depressive disorder. 2. Generalized anxiety disorder. 3. Obsessive-compulsive disorder. 4. Schizophrenia.

4 (1%) --- 1 (17%) 2 (5%) 3 (3%)

A client has a history of schizophrenia, controlled by haloperidol (Haldol). During an assessment, the nurse notes continuous restlessness. Which medication would the nurse expect the physician to prescribe for this client? 1. Haloperidol (Haldol). 2. Fluphenazine decanoate (Prolixin Decanoate). 3. Clozapine (Clozaril). 4. Benztropine mesylate (Cogentin).

4 (anticholinergic to treat EPS such as akathisia) --- 1, 2, 3 (antipsychotics that cause EPS; akathisia would increase)

The nurse is interviewing a client who states, "The dentist put a filling in my tooth I now receive transmissions that control what I think and do." The nurse accurately documents this symptom with which charting entry? 1. "Client is experiencing a delusion of persecution." 2. "Client is experiencing a delusion of grandeur." 3. "Client is experiencing a somatic delusion." 4. "Client is experiencing a delusion of influence."

4 (certain objects/persons have control over their behavior) --- 1 (individual feels threatened and believes others intend harm) 2 (exaggerated feelings of importance) 3 (false idea about functioning of body)

Clients diagnosed with schizophrenia may have difficulty knowing where their ego boundaries end and others' begin. Which client behavior reflects this deficit? 1. The client eats only prepackaged food. 2. The client believes that family members are adding poison to food. 3. The client looks for actual animals when others state, "It's raining cats and dogs." 4. The client imitates other people's physical movements.

4 (echopraxia) --- 1 (paranoid thinking) 2 (delusions of persecution) 3 (concrete thinking)

A nursing instructor is teaching about the etiology of schizophrenia. What statement by the nursing student indicates an understanding of the content presented? 1. "Schizophrenia is a disorder of the brain that can be cured with the correct treatment." 2. "A person inherits schizophrenia from a parent." 3. "Problems in the structure of the brain cause schizophrenia." 4. "There are many potential causes for this disease, and its etiology is controversial."

4 (etiology is unclear) --- 1 (no cure for schizo) 2 (5-10% higher risk if parent has it but no biological marker found) 3 (may be a result of not cause of schizo)

A disheveled client diagnosed with schizophrenia has body odor and halitosis. Which nursing diagnosis reflects this client's current problem? 1. Social isolation. 2. Impaired home maintenance. 3. Interrupted family processes. 4. Self-care deficit.

4 (impaired ability to perform ADLs)

Which atypical antipsychotic medication has the highest potential for a client to experience serious side effects? 1. Haloperidol (Haldol). 2. Chlorpromazine (Thorazine). 3. Risperidone (Risperdal). 4. Clozapine (Clozaril).

4 (life-threatening SE of neutropenia) --- 1 (typical) 2 (typical) 3 (atypical but clozapine has higher risk of serious side effects)

Which intervention used for clients diagnosed with schizophrenia is a milieu therapy approach? 1. Assist family in dealing with life stressors caused by interactions with the client. 2. Engage in one-on-one interactions to discuss family dynamics. 3. Role-play to enhance motor and interpersonal skills. 4. Emphasize the rules and expectations of social interactions mediated by peer pressure.

4 (milieu tx - group and social interactions_ --- 1 (family tx) 2 (interpersonal) 3 (social skills training)

Which symptom experienced by a client diagnosed with schizophrenia would predict a less positive prognosis? 1. Hearing hostile voices. 2. Thinking the TV is controlling his or her behavior. 3. Continuously repeating what has been said. 4. Having little or no interest in work or social activities.

4 (negative symptoms of apathy_ --- 1 (positive symptom) 2 (positive symptom of a delusion) 3 (positive symptom of echolalia)

A client who is hearing and seeing things others do not is brought to the emergency department. Lab values indicate a sodium level of 160 mEq/L. Which nursing diagnosis would take priority? 1. Altered thought processes R/T low blood sodium levels. 2. Altered communication processes R/T altered thought processes. 3. Risk for impaired tissue integrity R/T dry oral mucous membranes. 4. Imbalanced fluid volume R/T increased serum sodium levels.

4 (physiological problems but be corrected first) --- 1 (hypernatremia NOT hypo) 2 (secondary to electrolyte imbalance) 3 (secondary to electrolyte Imbalance)

A 21 year-old client, being treated for asthma with a steroid medication, has been experiencing delusions of persecution and disorganized thinking for the past 6 months. Which factor may rule out a diagnosis of schizophrenia? 1. The client has experienced signs and symptoms for only 6 months. 2. The client must hear voices to be diagnosed with schizophrenia. 3. The client's age is not typical for this diagnosis. 4. The client is receiving medication that could lead to thought disturbances.

4 (steroids can precipitate thought disorders; dx cannot be due to substances) --- 1 (has 2 symptoms experienced in a 6 mo period) 2 (not experiencing auditory hallucinations) 3 (falls within age range)

When one identical twin has been diagnosed with schizophrenia, the other twin has approximately a _____ % chance of developing the disease.

50%

A client is newly prescribed hydroxyzine (Atarax) 50 mg qhs and clozapine (Clozaril) 25 mg bid. Which is an appropriate nursing diagnosis for this client? 1. Risk for injury R/T serotonin syndrome. 2. Risk for injury R/T possible seizure. 3. Risk for injury R/T clozapine toxicity. 4. Risk for injury R/T depressed mood.

[antihistamine + atypical] 2 (clozapine lowers seizure threshold) --- 1 (hydroxyzine affects serotonin but clozapine doesn't) 3 (no test for clozapine blood levels; excessive causes sedation or hypersalivation) 4 (not used to treat depression)

A client has been prescribed ziprasidone (Geodon) 40 mg bid. Which of the following interventions are important related to this medication? Select all that apply. 1. Obtain a baseline EKG initially and periodically throughout treatment. 2. Teach the client to take the medication with meals. 3. Monitor the client's pulse because of the possibility of palpitations. 4. Institute seizure precautions and monitor closely. 5. Watch for signs and symptoms of a manic episode.

[atypical] 1 (can elongate QT interval) 2 (w/ meals for effective absorption) 3 (SE and should be monitored) --- 4 (seizure precautions with bupropion and clozapine) 5 (manic episode not SE)

A client prescribed quetiapine (Seroquel) 50 mg bid has a nursing diagnosis of risk for injury R/T sedation. Which nursing intervention appropriately addresses this client's problem? 1. Assess for homicidal and suicidal ideations. 2. Remove clutter from the environment to prevent injury. 3. Monitor orthostatic changes in pulse or blood pressure. 4. Evaluate for auditory and visual hallucinations.

[atypical] 2 (SE is sedation = safety) --- 1 (important but not part of diagnosis) 3 (important but not part of diagnosis) 4 (important but not part of diagnosis)

A client is prescribed aripiprazole (Abilify) 10 mg qam. The client complains of sedation and dizziness. Vital signs reveal B/P 100/60 mm Hg, pulse 80, respiration rate 20, and temperature 97.4°F. Which nursing diagnosis takes priority? 1. Risk for nonadherence R/T irritating side effects. 2. Knowledge deficit R/T new medication prescribed. 3. Risk for injury R/T orthostatic hypotension. 4. Activity intolerance R/T dizziness and drowsiness.

[atypical] 3 (SE of abilify) --- 1 (concern but not priority) 2 (concern not priority) 4 (concern but not priority)

A client diagnosed with schizophrenia is experiencing anhedonia. Which nursing diagnosis addresses the client's problem that this symptom may generate? 1. Disturbed thought processes. 2. Disturbed sensory perception. 3. Risk for suicide. 4. Impaired verbal communication.

[inability to experience pleasure] 3 --- 1, 2, 4 (doesn't address anhedonia)

A client is prescribed olanzapine (Zyprexa Relprevv). Which of the following client statements indicate that teaching regarding this medication has been effective? Select all that apply. 1. "I must stay in the facility and be monitored for 3 hours after receiving the injection." 2. "I cannot drive for the remainder of the day." 3. "I must register paperwork with the drug company." 4. "I need to notify staff if I get overly tired or confused." 5. "After my first three injections, the risk of adverse reaction decreases."

[long acting IM/4 weeks] 1, 2, 3, 4 --- 5 (cumulative risk of post injection delirium/sedation)

For the past year, a client has received haloperidol (Haldol). The nurse administering the client's next dose notes a twitch on the right side of the client's face and tongue movements. Which nursing intervention takes priority? 1. Give haloperidol and benztropine (Cogentin) 1 mg IM prn per order. 2. Assess for other signs of hyperglycemia resulting from the use of the haloperidol. 3. Check the client's temperature and assess mental status. 4. Hold the haloperidol and call the physician.

[typical] 4 (reflect tardive dyskinesia) --- 1 (hold until physician notified) 2 (should be monitored but symptoms don't reflect hyperglycemia) 3 (symptoms of NMS)