psychotic disorders

A client is ready to be discharged with a prescription for haloperidol, 10 mg to be taken orally, twice a day. While reinforcing information before discharge, which instruction would the nurse reemphasize?

"Apply a sunscreen before being going outside in the sun."

A client tells the nurse that a voice keeps telling him to crawl on his hands and knees like a dog. Which response by the nurse is most appropriate for this client?

"Even though I don't hear the voices, I understand that you do."

A schizophrenic client states, "I hear the voice of King Tut." Which response by the nurse would be therapeutic?

"I don't hear the voice, but I know you hear what sounds like a voice."

A client with a history of schizophrenia is having hallucinations. The client shouts to the nurse, "You're stepping on spiders! Move aside. Don't you see them?" Which response by the nurse would be best?

"I don't see them, but I know you believe you do."

A client is taking chlorpromazine as part of a treatment plan. Which response by the client indicates that the client understands the education about the drug?

"I need to schedule appointments for routine medication checks."

A client was the driver in an automobile accident in which a 3-year-old was killed; the client is now experiencing dissociative amnesia. After reviewing the treatment plan with the client, the nurse determines that the client demonstrates understanding by which statement?

"I'll attend my hypnotic therapy sessions prescribed by my psychiatrist."

The chart documentation of a client with paranoid personality disorder is listed below:10/151830The client stays by oneself as much as possible during the afternoon. The client paced the hallway at times and was irritated if approached by staff or other clients. The client questioned another male client and accused that client of lying. At the beginning of the shift the nurse spoke to the client accused of lying.Which statement, from the client accused of lying, would require further intervention?

"If I have an opportunity, I will not let him get away with this."

A client was hospitalized after a family member filed a petition for involuntary hospitalization for safety reasons. The family member seeks out the nurse because the client is angry and refuses to talk. The family member states, "I feel so guilty about my decision." Which response by the nurse is the most empathic?

"It's common for family members to feel this way. Can you tell me more?"

A nurse is reinforcing the teaching plan with a client diagnosed with dissociative identity disorder (DID). Which statement by the client indicates that the education has been effective?

"My brain has temporarily hidden my memories of the rape to protect me."

A client tells the 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 is brought to the clinic by a family member. The family member states that the client seems "depressed" and "isn't talking very much." What is the best response by the nurse?

"The client is experiencing some of the negative signs of schizophrenia."

Which concept is most important for a nurse to communicate to a client preparing to sign an informed consent for electroconvulsive therapy (ECT)?

"You may experience a time of confusion after the treatment."

A client is prescribed haloperidol. When reinforcing the teaching plan about the drug, which instruction would the nurse emphasize?

"You should report feelings of restlessness or agitation at once."

The nurse is reinforcing education for a client taking risperidone for the treatment of symptoms related to schizophrenia. Which statement, made by the client, would indicate the reinforcement was effective? Select all that apply.

-"If the dose of risperidone is increased, I will report any seizure activity." -"I will notify the health care provider if I notice any bruising. "

A client with delusional thinking is admitted to the mental health unit. He or she presently shows a lack of interest in eating. The client states, "I am unworthy of eating and if I eat, my children will die." Which nursing interventions are most appropriate for this delusional client? Select all that apply.

-Divert the client's focus from unworthiness to reality. -Do not agree with the client's delusion. -Restrict the client's access to food except at specified meal and snack times.

The nurse is caring for a schizophrenic client who becomes violent and delusional. Which therapeutic actions are best? (Select all that apply.)

-Obtain additional staff assistance as needed. -Ensure the safety of the client and others in the area. -If restraints are required, explain what is being done and why.

A nurse is talking with a delusional client when the fire alarm sounds and a staff member closes the door to the client's room. The client becomes very agitated and declares, "The aliens have arrived!" Which actions are appropriate for the nurse to take? Select all that apply.

-staying with the client until the nurse receives further instructions -continuing to speak to the client in a reassuring tone

Since admission 4 days ago, a client has refused to take a shower, stating, "There are poison crystals hidden in the showerhead. They'll kill me if I take a shower." Which action is most appropriate?

Accept the client's fears, allowing the client to take a sponge bath.

The nurse is caring for a client who has schizophrenia. What is the first-line treatment for this client?

Antipsychotics

A 62-year-old male client with schizophrenia tells a nurse that he sexually molests his cousin. He tells the nurse that he's never told anyone and begs her to keep his secret. Which action should the nurse take?

Document the details of the conversation and notify the nursing supervisor.

A male with an antisocial personality disorder is court-mandated to receive counseling after being detained by law enforcement officials. The chart entry reads:10/151130The client came to the group therapy session and was verbally aggressive to other clients. The group leader set limits on his behavior, reinforced the group rules and guidelines. At two different times the client made excuses for his behavior, stating, "I really don't have to be here," and minimized the comments of other group members.Which priority action must the nurse group leader initiate?

Formulate an individual contract for appropriate behavior during the group.

A client who's taking antipsychotic medication develops a very high temperature, severe muscle rigidity, tachycardia, and rapid deterioration in mental status. The nurse suspects what severe complication of antipsychotic therapy?

Neuroleptic malignant syndrome (NMS)

A 32-year-old homeless client is referred to an outpatient treatment program for delusional behavior. A nurse notes during the history-taking process that the client eats only one meal a day, which is high in fat and contains no vegetables. The client also states that she rarely eats fruit. Which approach can the nurse use to help the client eat more nutritious meals?

Provide the client with a nutritional lunch and arrange for the nutritionist and psychiatrist to see the client after lunch.

A registered nurse is caring for a group of clients on a psychiatric unit. Which task can the nurse delegate to the licensed practical/vocational nurse?

Redressing lacerations on the wrists of a client who attempted suicide.

A client has followed an antipsychotic medication regimen for a number of years. The health care provider treats a urinary tract infection with antibiotic therapy. Which action would be most appropriate?

Reinforce instruction on the medication, possible adverse effects, and a return demonstration for teaching effectiveness.

A nurse observes that an alternate personality (a child) of an adult client with dissociative identity disorder (DID) is in control. The client is sitting in the dayroom, interacting with others. Which action would be most appropriate?

Remove the client from the dayroom and reorient in a safe place.

The nurse is developing a teaching plan for a client receiving clozapine. The nurse should stress the importance of which aspect of follow-up care?

Routine complete blood count (CBC) with differential

A client with persistent, severe schizophrenia has been treated with phenothiazines for the past 17 years. Now the client's speech is garbled as a result of drug-induced rhythmic tongue protrusion. What is another name for this extrapyramidal symptom?

Tardive dyskinesia

The nurse is preparing to administer chlorpromazine to a client with schizophrenia. Which circumstance, if noted in this client's history, would cause the nurse to notify the health care provider for accuracy of the prescription?

The client is also receiving labetalol.

The nurse is preparing to administer chlorpromazine to a client with schizophrenia. Which circumstance, noted in the client's history, would cause the nurse to notify the health care provider for accuracy of the prescription?

The client is also receiving labetalol.

A client states to the nurse, "I was watching television and the person in the commercial was trying to send me a message to be careful about who I talk with in this place because they will betray me." What behavior disturbance is the client displaying to the nurse?

The client is having delusions of reference.

When reviewing a client's chart, the nurse sees the progress note. Which statement about the client's condition is most accurate?

The client may not be motivated to change their behavior or their lifestyle.

Teaching for women in their childbearing years who are receiving antipsychotic medications should include which of the following facts?

The client should continue using contraception during periods of amenorrhea.

What should be charted by the nurse when the client has an involuntary commitment or formal admission status?

The client's receipt of information about status and rights should be charted.

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 etiology of schizophrenia is best described by:

a combination of biological, psychological, and environmental factors.

A client is being treated at a community mental health clinic. A nurse has been instructed to observe for any behaviors indicating dissociative identity disorder (DID). Which behavior would be included?

changes in dress, mannerisms, and voice

A client with schizophrenia was admitted to the psychiatric unit during the night. The next morning, the client begins to call the nurse by a sister's name. Which intervention is best?

correcting the misidentification and orienting the client to the unit and staff

A client is referred to a mental health clinic by the court for harassing a couple next door and claiming that the husband was in love with her. She wrote love notes and called him on the telephone throughout the night. The client is employed and has had no problems with her job. The nurse interprets these findings as suggesting which condition?

delusional disorder

A client is admitted after being found on a highway, throwing rocks and debris and yelling at motorists. When approached by the nurse, the client shouts, "You're the one who stole my husband from me." The nurse interprets the client's statement as indicating which condition?

delusional experience

A client is admitted to the psychiatric unit with active psychosis. The physician diagnoses schizophrenia after ruling out several other conditions. Schizophrenia is characterized by:

disturbances in affect, perception, and thought content and form.

A client with a history of bipolar disorder came to the hospital with an exacerbation. The client has been prescribed lithium and has not taken it for the past 2 weeks. What finding is the nurse likely observe?

flight of ideas

A client with schizophrenia approaches a nurse and states, "I hear voices telling me that you are evil and deserve to die." The nurse interprets the client's statement as indicating which sign or symptom?

hallucination

A client diagnosed with schizophrenia several years ago tells the nurse about feeling "very sad." The nurse observes that the client is smiling when saying it. When documenting this observation, the nurse would describe it using which term?

inappropriate affect

A nurse is carrying out the plan of care developed for a client diagnosed with dissociative identity disorder (DID). Which intervention would be the priority for this client?

maintaining consistency when interacting with the client

A nurse is working with the interdisciplinary team to develop an appropriate plan of care for a client with depersonalization/derealization disorder (DID). Which factor would be a priority for the team to address?

out-of-body experiences

A nurse is implementing interventions for the care of a client admitted with a diagnosis of schizotypal personality disorder. Which behavior would the nurse most likely observe in the client during this situation?

paranoid thoughts

A nurse is caring for a client with dissociative amnesia who is exhibiting signs of low self-esteem. The nurse determines that the interventions have been successful when the client demonstrates which behavior?

participation in new activities

A client with depersonalization/derealization disorder spends much of the day in a dreamlike state, ignoring personal care needs. What situation is this behavior most likely related to?

perceptual impairment

A nurse is reviewing the interdisciplinary plan of care for a client experiencing hallucinations. Which intervention would the nurse most likely identify as being included in the plan?

providing a competing stimulus that distracts from the hallucinations

An adolescent client with a diagnosis of schizophrenia has become very clingy and begins sucking their thumb while interacting with the nurse. The nurse understands that these behaviors indicate which defense mechanism?

regression

A nurse is reviewing a client's history. Which characteristic would lead the nurse to suspect that a client is experiencing a depersonalization/derealization disorder?

sensation of detachment from body or mind

A client states, "I can't eat because my bowels have turned against me." The nurse determines that the client is exhibiting which behavior?

somatic delusion

A client with schizophrenia tells the nurse, "My intestines are rotted from the worms chewing on them." This statement indicates a:

somatic delusion.

A client with schizophrenia has been stable for some time. What action is most important for preventing relapse?

taking prescribed medications consistently

The nurse obtains data related to auditory hallucinations from a client with schizophrenia. Which behavior is most suggestive of this symptom?

tilting the head to one side

A client with dissociative identity disorder (DID) is admitted to an inpatient psychiatric unit. A nurse-manager asks all staff to attend a meeting. Which is the most likely reason for the meeting?

to allow staff members to discuss concerns about working with a client with DID