PrepU Chapter 72

The nurse observes a client with schizophrenia sitting alone, laughing occasionally, and turning his head as if listening to another person. The nurse assesses this behavior to indicate that the client is experiencing auditory hallucinations and says:

"Are you hearing something?"

A 73-year-old man has been brought to the emergency department by his daughter and son-in-law due to abrupt and uncharacteristic changes in behavior, including impairments of memory and judgement. The subsequent history and diagnostic testing have resulted in a diagnosis of delirium. Which of the following teaching points about the client's diagnosis should the nurse provide to his family?

"If the underlying cause of delirium is identified and treated, most people return to their previous level of functioning."

A client asks a nurse if she hears the voice of the nonexistent man speaking to him. Which response is best?

"No, I don't hear him, but I know you do. What's he saying?"

The nurse enters the room of a client with schizophrenia the day after he has been admitted to an inpatient setting and says, "I would like to spend some time talking with you." The client stated straight ahead and remains silent. The best response by the nurse would be:

"You don't need to talk right now. I'll just sit here for a few minutes."

The nurse is caring for a client who has been prescribed rivastigmine (Exelon) 2.5 mg twice a day. The medication is available as rivastigmine (Exelon) 2mg/mL. How much will the nurse administer to the client for one dose?

1.3 2.5mg / 1 x 1mL / 2mg = 1.25mL = 1.3mL

The nurse is observing a client who is sitting alone in the day room. The client appears intently focused on the chair next to him. Suddenly the client begins laughing hysterically and making frantic hand gestures at the chair. When the nurse approaches the client, he looks over at the chair, whispers something unintelligible, and shakes his head. Based on this observation the nurse would assess the client's behavior as:

A hallucination

Which term describes an inability to recognize or name objects despite intact sensory abilities?

Agnosia

During the initial interview, a schizophrenic client stated to the nurse, "I don't enjoy things anymore. I used to love to read mystery books, but even that isn't enjoyable now." The nurse correctly identifies the client is experiencing which of the following conditions?

Anhedonia

A 49-year-old client is admitted to the emergency department frightened and reporting that he's hearing voices telling him to do bad things. Which intervention should be the nurse's priority?

Assess the nature of the commands by asking the client what the voices are saying.

A client is sitting in the day room / dining area and laughing out loud, shaking his head, and whispering behind his hand. Suddenly he begins banging his head against the wall. Which of the following interventions is most appropriate?

Calmly walk over to the client and say, "Tell me what's going on."

An older client has developed influenza. Three days into the illness the client became disoriented and confused, and didn't recognize family members. What would the nurse suspect is occurring?

Delirium

A client is admitted after being found on a highway, hitting at cars and yelling at motorists. When approached by the nurse, the client shouts, "You're the one who stole my husband from me." Which condition describes the client's condition?

Delusional experience

A client had gradually been losing cognitive function and is understandably fearful. What would the physician likely diagnose?

Dementia

Which type of therapy involves shifting the client's attention and energy to a more neutral topic?

Distraction

A client is repeating every word that the nurse says. This would be correctly documented as which of the following?

Echolalia

As a nurse planning care for a client with paranoid delusions, which of the following will be the priority goal?

Establishing trust

A client with schizophrenia is hearing voices that tell him to kill himself. The nurse understands that this client is experiencing:

Hallucination

Which cluster of symptoms would indicate schizophrenia?

Hallucinations or delusions and decreased ability to function in society.

Symptoms of schizophrenia are classified as positive symptoms and negative symptoms. Which symptom would be classified as a negative symptom?

Inability to express emotions

A client with schizophrenia is admitted to the inpatient unit. He does not speak when spoken to but has been observed talking to himself on occasion. At this time, the priority goal for this client is to:

Increase his reality orientation

Which condition is not a characteristic of schizophrenia?

Memory loss

Which of the following life-threatening reactions, related to neuroleptic medication, is exhibited by rigidity, fever, hypertension, and diaphoresis?

Neuroleptic malignant syndrome

Why is it important for nurses to assess blood pressure in clients receiving antipsychotic drugs?

Orthostatic hypotension is a common side effect.

A client has experienced a gradual flattening of affect, confusion, and withdrawal and has been diagnosed with Alzheimer's disease. The nurse assesses which of the following additional characteristics of this disorder?

Personality change, wandering, and inability to perform purposeful movements

The nurse understands that client's with cognitive disorders often experience spatial confusion as their diseases progress. Which of the following measures should be undertaken to maximize clients' safety and independence when navigating an inpatient facility?

Post arrows, signs, and paths in the facility and increase lighting.

Which action by a nurse is an appropriate therapeutic intervention for a client experiencing hallucinations?

Providing a competing stimulus that distracts from the hallucinations

A client is admitted with a diagnosis of paranoid schizophrenia. The student nurse asks the charge nurse about the approach to take with the client, who has been exhibiting hostility and isolation. Which approach would be the most appropriate direction from the charge nurse?

Respect the client's need for personal space and avoid physical contact.

A resident at a long-term care facility is active and independent despite some urinary incontinence. The client is typically alert and oriented but has begun to display confusion and disorientation. What is likely the problem?

UTI

Which of the following is a combination of jumbled words and phrases that are disconnected or incoherent and make no sense to the listener?

Word salad