Psychotic Disorder Pass Point

During a psychotic episode, a client with schizophrenia is unable to focus on interactions. The client has cognitive disturbances and poor attention, concentration, and memory. The client also has a history of suicide attempts. The client tells the nurse, "I do not want you to contact my family. I don't even have to talk to you." Which statement is the most appropriate nursing response?

"Anything you say about your feelings is confidential but your care involves the whole team so we can all work together."

A client with a diagnosis of schizophrenia and paranoid personality disorder asks the nurse, "How do I know what's really in those pills?" Which response by the nurse is best?

"How would you feel if I allowed you to open the individual medication wrappers?"

At an outpatient visit 3 months after discharge from the hospital, a client says he has stopped his olanzapine even though it controls his symptoms of schizophrenia better than other medications. "I've gained 20 lb (9.1 kg) already. I can't stand it anymore." Which response by the nurse is most appropriate?

"I can help you with a diet and exercise plan to keep your weight down."

The nurse should judge client education regarding valproic acid as effective if the client states which statement?

"I might need to take the valproic acid for a long time."

A client with bipolar disorder, manic phase, begins to swear at the nurse when reminded to limit telephone calls to 10 minutes. Which response should the nurse make?

"Stop! Swearing is not appropriate behavior."

A client tells a nurse that people from Mars are going to invade the Earth. Which response by the nurse would be therapeutic?

"That must be frightening to you. Can you tell me how you feel about it?"

A client with schizophrenia and delusions tells a nurse, "There is a man wearing a red coat who's out to get me." The client exhibits increasing anxiety when focusing on the delusion. Which response by the nurse is appropriate?

"This subject seems to be troubling you. Let's walk to the activity room."

A young client diagnosed with schizophrenia is talking with the nurse and says, "You know, when I thought everyone was out to get me, I was staying in my apartment all the time. Now, I would like to get out and do things again." What is the best initial response by the nurse?

"What activities did you enjoy in the past?"

A client with schizophrenia, who has a history of being placed in seclusion for physically assaulting other clients, is showing signs of increased agitation. The client causing self-harm with fingernails to the face and eyes. All nursing attempts to reduce this behavior have failed. What should the nurse do next?

Apply physical restraints to protect the client, then contact the physician for orders.

The nurse observes that a client on a psychiatric unit is looking around the room with eyes darting to a chair in the corner. The client grimaces and then states, "Bastard," under his breath. Which nursing action is most appropriate?

Approach the client to interrupt the hallucinations.

An agitated client diagnosed with schizophrenia and the client's family arrive in the psychiatric unit for admission. Which action should the nurse perform first?

Assess the client's risk for suicide, homicide, or other violent behavior.

A client is sitting in the dining area and laughing out loud, shaking her head, and whispering behind her hand. Suddenly the client begins banging her head against the wall. Which intervention by the nurse is most appropriate?

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

Teaching for women of childbearing years who are receiving antipsychotic medications includes which statement?

Continue previous contraceptive use even if you're experiencing amenorrhea.

What should the nurse do when the client with a diagnosis of schizophrenia walks into group naked?

Lead the client to his room and help him dress if he needs assistance.

The nurse is working in a community mental health clinic. A client who is diagnosed with schizophrenia is taking clozapine and reports of a sore throat. What is the most appropriate action for the nurse to take?

Obtain an order for the client to have a white blood cell count drawn.

A client with a chronic mental illness has worked as a hotel maid for the past 3 years. She tells the nurse she is thinking of quitting her job because "voices on television are talking about me." What should the nurse do first?

Obtain information about the client's medication compliance.

A nurse is teaching a client about the prescribed drugs, chlorpromazine and benztropine. What evaluation would indicate a therapeutic response to these drugs?

The client is experiencing less psychosis and a decrease in extrapyramidal symptoms.

A client is admitted to the psychiatric unit exhibiting extreme agitation, disorientation, and incoherence of speech with frantic and aimless physical activity and grandiose delusions. Which would the highest priority goal in planning nursing interventions?

The client will show no self-harm or harm to staff.

The nurse is reviewing laboratory values of a client receiving clozapine. Which of the following laboratory values does the nurse immediately report to the health care provider (HCP)?

WBC of 3,500

A nurse caring for a client diagnosed with schizophrenia should perform which intervention when the client becomes suspicious and refuses to take their medication?

Wait for a short time and then attempt to administer the medication

The parents of a teenager recently diagnosed with schizophrenia ask the nurse about whether their other children will be susceptible as well. The nurse explains that schizophrenia is caused by:

a combination of biological, psychologic, and environmental factors.

An outpatient client who has a history of paranoid schizophrenia and chronic alcohol dependency has been taking risperidone for several months. She reports that she stopped drinking 4 days ago. The client is very frightened by the tactile hallucinations of bugs crawling under her skin. Which factor should the nurse incorporate into the plan of care when explaining the tactile hallucinations?

alcohol withdrawal

A client is unable to get out of bed and get dressed unless a nurse prompts every step. This is an example of which behavior?

avolition (impairment in the ability to initiate goal-directed activity.)

A client has been admitted to the emergency department. The client's family tells the nurse that the client has suddenly become lethargic and is "not making sense." The client has not had anything to eat or drink for the last 8 hours. The nurse further assesses the client using the Confusion Assessment Method (CAM). The client's responses to questions are rambling, and the client is not able to focus clearly to answer the nurse's questions. Based on these findings, the nurse should report that the client has which problem?

delirium

A nurse is caring for a client with schizoaffective disorder. The client is currently experiencing auditory hallucinations. Which nursing actions would take first priority for this client?

engaging the client in reality-based conversations

A client with schizophrenia comes to the outpatient mental health clinic 5 days after being discharged from the hospital. The client was given a 1-week supply of clozapine. The client tells the nurse that she has too much saliva and frequently needs to spit. The nurse interprets the client's statement as being consistent with which factor?

expected adverse effect of clozapine

The client with borderline personality disorder spends much time around the nurse's station, making numerous minor requests. The nurse interprets these behaviors as indicating which factor?

fears of abandonment and attention seeking

A client experiencing a schizophrenic episode is hospitalized. The client is attempting to hit and bite the staff. When the nurse phones the primary care provider for orders to help calm the client, the nurse anticipates what medication is likely to be ordered?

haloperidol

Which behavior indicates to the nurse that the client diagnosed with avoidant personality disorder is improving?

interacting with two other clients

Which group of characteristics should a nurse expect to see in the client with schizophrenia?

loose associations, grandiose delusions, and auditory hallucinations

A client diagnosed with paranoid personality disorder is hospitalized for physically threatening his wife because he suspects her of having an affair with a coworker. What approach should the nurse employ with this client?

matter-of-fact

A client who takes neuroleptic medication for treatment of chronic schizophrenia is admitted to the psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, and diaphoresis. Which life-threatening reaction do these findings suggest?

neuroleptic malignant syndrome

A nurse is planning care for a regressed, chronically ill client diagnosed with schizophrenia. What is the most appropriate milieu?

nurturance and supportive interaction focusing on individual needs

A client is admitted with a diagnosis of schizotypal personality disorder. Which signs would this client exhibit during social situations?

paranoid thoughts

A 20-year-old client diagnosed with paranoid schizophrenia is recovering from his first psychotic break. Before discharge from the hospital, the client becomes depressed and states, "I don't want this illness. I'm about to begin my junior year in college." Which issue would be most important for the nurse to address at this time?

potential for medication noncompliance

After working multiple shifts in the psychiatric intensive care unit, a nurse is becoming more distant and, at times, even irritable. The best action for the nurse to take would be to:

talk with the charge nurse and seek support from peers on the unit.

A client with a diagnosis of borderline personality disorder is admitted to the psychiatric unit. What assessment data obtained by the nurse correlates with the client's disorder?

unpredictable actions and intense interpersonal relationships