Psychotic Disorders

A client is brought to the hospital by the spouse, who states that the client has refused all meals for the past week and accused the spouse of trying to poison the client. During the initial interview, the client's speech, only partly comprehensible, reveals that the client's thoughts are controlled by delusions that the client is possessed by the devil. A health care provider diagnoses paranoid schizophrenia. Paranoid schizophrenia is best described as a disorder characterized by: severe mood swings and periods of low and high activity. olfactory and tactile hallucinations. preoccupation with persecutory delusions, anxiety, anger, and potential for violence. multiple personalities, one of which is more destructive than the others.

preoccupation with persecutory delusions, anxiety, anger, and potential for violence. Schizophrenia is best described as one of a group of psychotic reactions characterized by disturbed relationships with others and an inability to communicate and think clearly. Schizophrenic thoughts, feelings, and behavior are commonly evidenced by withdrawal, fluctuating moods, disordered thinking, and regressive tendencies. While some clients with schizophrenia may be at risk for violent behavior, people with schizophrenia generally are not prone to violence. Severe mood swings and periods of low and high activity are typical of bipolar disorder. Multiple personality, sometimes confused with schizophrenia, is a dissociative personality disorder, not a psychotic illness. Many schizophrenic clients have auditory hallucinations; olfactory and tactile hallucinations are much less common with schizophrenia and tend to be associated with other disorders.

A client's medication order reads, "Thioridazine 200 mg P.O. q.i.d. and 100 mg P.O. PRN" A nurse should: question the physician about the order. administer the order for 200 mg P.O. q.i.d. but not for 100 mg P.O. PRN. administer the medication as ordered but observe the client closely for adverse effects. administer the medication as ordered.

question the physician about the order. The nurse must question this order immediately. Thioridazine has an absolute dosage ceiling of 800 mg/day. Any dosage above this level places the client at high risk for toxic pigmentary retinopathy, which can't be reversed. As written, the order allows for administering more than the maximum 800 mg/day; it should be corrected immediately, before the client's health is jeopardized.

The client with histrionic personality disorder is melodramatic and responds to others and situations in an exaggerated manner. The nurse should recommend which activity for this client? party planning music group role-playing cooking class

role-playing The nurse should use role-playing to teach the client appropriate responses to others in various situations. This client dramatizes events, draws attention to self, and is unaware of and does not deal with feelings. The nurse works to help the client clarify true feelings and learn to express them appropriately. Party planning, music group, and cooking class are therapeutic activities, but will not help the client specifically learn how to respond appropriately to others.

How soon after chlorpromazine administration should a nurse expect to see a client's delusional thoughts and hallucinations eliminated? several hours several weeks several days several minutes

several weeks Although most phenothiazines produce some effects within minutes to hours, their antipsychotic effects may not appear until several weeks after the start of therapy.

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

somatic delusion. Somatic delusions focus on bodily functions or systems and commonly include delusions about foul odor emissions, insect infestations, internal parasites, and misshapen parts. Delusions of persecution are morbid beliefs that one is being mistreated and harassed by unidentified enemies. Delusions of grandeur are gross exaggerations of one's importance, wealth, power, or talents. Jealous delusions are delusions that one's spouse or lover is unfaithful.

When developing the plan of care for a client diagnosed with a personality disorder, the nurse plans to assist the client primarily with what factor? specific dysfunctional behaviors manipulation of the environment examination of developmental conflicts psychopharmacologic compliance

specific dysfunctional behaviors The nurse should plan to assist the client who has a personality disorder primarily with specific dysfunctional behaviors that are distressing to the client or others. The client with a personality disorder has lifelong, inflexible, and dysfunctional patterns of relating and behaving. The client commonly does not view the behavior as distressful. The client becomes distressed because of others' reactions and behaviors toward the client, which causes the client emotional pain and discomfort. Psychopharmacologic compliance is not a primary need because medication does not cure a personality disorder. Medication is prescribed if the client has a severe symptom that interferes with functioning, such as severe anxiety or depression. Examination of developmental conflicts usually is not helpful because of the ingrained dysfunctional ways of thinking and behaving. It is more useful to help the client with changing dysfunctional behaviors. Although milieu management is a component of care, the client usually is proficient enough in the manipulation of the environment to meet personal needs.

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: request vacation time in order to achieve emotional restoration. talk with the charge nurse and seek support from peers on the unit. continue to work and recognize that these feelings are normal. ask the charge nurse if another, less-demanding assignment is available.

talk with the charge nurse and seek support from peers on the unit. Talking with the charge nurse and the nurse's own peers provides an opportunity for the nurse to express legitimate feelings and receive support and encouragement from others who understand. Although requesting vacation time may be helpful for the nurse in the short term, it isn't the best step to take. Requesting a less-demanding assignment is avoidant and doesn't address the nurse's feelings. Continuing to work without dealing with the feelings doesn't allow the nurse to provide the most therapeutic care to the clients. One of the most important factors in psychiatric nursing is self-knowledge.

A nurse is preparing for the discharge of a client who has been hospitalized for schizophrenia. The client's spouse expresses concern over whether the client will continue to take daily ordered medication. The nurse should inform the spouse that: the spouse can easily mix the medication in food if the client stops taking it. the client knows the medication must be taken as ordered to avoid future hospitalizations. the client can be given a long-acting medication that is administered every 1 to 4 weeks. the concern is valid, but the client is an adult and has the right to make decisions.

the client can be given a long-acting medication that is administered every 1 to 4 weeks. Long-acting psychotropic drugs can be administered by depot injection every 1 to 4 weeks. These agents are useful for noncompliant clients because the client receives the injection at the outpatient clinic. A client has the right to refuse medication, but this issue isn't the focus of discussion at this time. Medication should never be hidden in food or drink to trick the client into taking it; in addition to destroying the client's trust, doing so would place the client at risk for overmedication or undermedication because the amount administered is hard to determine. It would be unrealistic to assume the client knows medication must be taken to avoid future hospitalizations.

When discharging a client after treatment for a dystonic reaction, an emergency department nurse must ensure that the client understands: the client shouldn't buy drugs on the street. although uncomfortable, this reaction isn't serious. the client must take benztropine as ordered to prevent a return of symptoms. results of treatment are rapid and dramatic but may not last.

the client must take benztropine as ordered to prevent a return of symptoms. An oral anticholinergic agent such as benztropine is commonly ordered to control and prevent the return of symptoms. Dystonic reactions are typically acute and reversible. Dystonic reactions can be life-threatening when airway patency is compromised. Lecturing the client about buying drugs on the street isn't appropriate.

A client is admitted to the psychiatric unit accompanied by her husband. She brings six suitcases and three shopping bags. She orders the nurse to carry her bags. Her husband states she has been purchasing items that they cannot afford and has not slept for 4 nights. Which additional information would be a priority for the nurse to seek from the client's husband? the client's usual sleeping pattern their current financial status the client's fluid and food intake whether or not the client becomes agitated easily

the client's fluid and food intake Assessing nutritional status is a priority in this situation. Clients with bipolar disorder, manic phase, commonly do not have time to eat or drink because of their state of constant activity and easy distractibility. Altered nutritional status and constant physical activity can lead to malnutrition, weight loss, and physical exhaustion. These states can lead to death if appropriate intervention is not instituted.Financial status is neither important nor something that the nurse can modify.Clients with bipolar disorder, manic phase, have disturbed sleep patterns; however, their hydration and nutritional status are the first priority.A common behavior of clients with bipolar disorder, manic phase, is to exhibit hostility when their personal desires are limited, so it is not necessary to seek this information at this time.

When conducting a mental status examination with a newly admitted client who has a diagnosis of paranoid schizophrenia, the client states, "I'm being followed; it's not safe. They are monitoring my every move." In which area of the mental status examination should the nurse document this information? insight judgment quality of speech thought content

thought content The client is voicing paranoid delusions of being followed and monitored. Presence of delusions is described in the area of thought content in the mental status examination. The speech section would typically include documentation of disturbances in speech or pressured speech. In the insight section, the nurse would document information reflecting a lack of insight—for example, statements such as "I don't have a problem." In the judgment section, the nurse would document information reflecting a lack of judgment—for example, poor choices such as buying a gun for self-protection.

A client has been receiving chlorpromazine to treat psychosis. Which findings should alert the nurse that the client is experiencing pseudoparkinsonism? involuntary rolling of the eyes tremors, shuffling gait, and masklike face extremity and neck spasms, facial grimacing, and jerky movements restlessness, difficulty sitting still, and pacing

tremors, shuffling gait, and masklike face Pseudoparkinsonism may appear 1 to 5 days after starting an antipsychotic and may also include drooling, rigidity, and "pill rolling." Akathisia may occur several weeks after starting antipsychotic therapy and consists of restlessness, difficulty sitting still, and fidgeting. An oculogyric crisis characterized by uncontrollable rolling back of the eyes and, along with dystonia, should be considered a medical emergency. Dystonia may occur minutes to hours after receiving an antipsychotic and may include extremity and neck spasms, jerky muscle movements, and facial grimacing.

A client with schizophrenia is withdrawn and suspicious of others, and projects blame. The client's behavior reflects problems in which stage of development as identified by Erikson? intimacy versus isolation autonomy versus shame and doubt initiative versus guilt trust versus mistrust

trust versus mistrust The client who is withdrawn, is suspicious, and projects blame is exhibiting problems in trust versus mistrust. Shame and doubt would be reflected as low self-esteem and suspiciousness. Guilt would be reflected in self-blame for all problems. Isolation would be reflected in a lack of long-term relationships.

The health care provider prescribes risperidone 1 mg orally, two times a day for a client from a group home admitted to the hospital with severe antisocial behavior. The nurse determines that this dose is: typical when initiating therapy. too low for the client. too high for the client. typical when initiating therapy but it should be tapered down in 1 week.

typical when initiating therapy. Although medications are rarely effective in treating antisocial personality disorder, short-term use of antipsychotic medications may be helpful to decrease irritability and aggressive behavior. Treatment with risperidone typically begins with 1 mg twice a day for an adult and 0.5 mg twice a day for an elderly client. Dosage is increased, not tapered, over 1 week. Recommended dosages range from 4 to 6 mg/day. This dosage is neither too high nor too low for the client.

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? apathy, detachment, and lack of affectionate feelings chronic extreme pain that cannot be explained by any medical condition unpredictable actions and intense interpersonal relationships inability to function as a responsible parent

unpredictable actions and intense interpersonal relationships A client with borderline personality disorder displays a pervasive pattern of unpredictable behavior, mood, and self-image. Interpersonal relationships may be intense and unstable, and behavior may be inappropriate and impulsive. Although the client's impaired ability to form relationships may affect parenting skills, the inability to function as a responsible parent is more typical of antisocial personality disorder. Somatic symptoms characterize avoidant personality disorder. Apathy, detachment, and lack of affectionate feelings typify schizoid and schizotypal personality disorders.

A client with a diagnosis of schizophrenia is admitted to the psychiatric hospital in a catatonic state. During the physical examination, the client's arm remains outstretched after the nurse obtains pulse and blood pressure readings, and the nurse must reposition the arm. This client is exhibiting: retardation. waxy flexibility. suggestibility. negativity.

waxy flexibility. Waxy flexibility, the ability to assume and maintain awkward or uncomfortable positions for long periods, is characteristic of catatonic schizophrenia. Clients commonly remain in these awkward positions until someone repositions them. Clients with dependency problems may demonstrate suggestibility, a response pattern in which one easily agrees to the ideas and suggestions of others rather than making independent judgments. Catatonic clients may also exhibit negativity (for example, resistance to being moved or being asked to cooperate) and retardation (slowed movement).

A mental health nurse receives the following phone messages. Which client with the nurse call back first? A client with a history of illicit drug use who stated "My family would be happier if I was not around." A parent of a child with schizophrenia who refuses to take the prescribed medications. A client newly diagnosed with bipolar disorder reporting an inability to sleep for several days. A client with depression who states "I lost 10 lb (4.5 kg) in 2 weeks because I am never hungry."

A client with a history of illicit drug use who stated "My family would be happier if I was not around." A client who states the family would be better off without him or her should be immediately assessed for suicidal ideations. Although clients with insomnia, weight loss, and noncompliance with medication regimen should be addressed, these are not the priority action.

A client admitted with a diagnosis of schizoaffective disorder, manic phase, who is currently taking fluoxetine, valproic acid, and olanzapine as prescribed, has had an increase in manic symptoms in the past week. The health care provider prescribes a valproic acid blood level to be drawn at once. What does the nurse understand is the rationale for this prescription? Fluoxetine can decrease the effectiveness of the valproic acid. All clients taking valproic acid need periodic valproic acid levels drawn. The valproic acid level is needed before a short course of lorazepam for agitation can be prescribed. A decrease in the level of valproic acid could explain the increase in manic symptoms.

A decrease in the level of valproic acid could explain the increase in manic symptoms. Valproic acid is commonly used to treat manic symptoms. Therefore, a decrease in the valproic acid level could explain the increase in manic symptoms. Periodic determinations of the valproic acid level are necessary to determine the effectiveness of the drug. However, the stat nature of the specimen to be drawn indicates an immediate problem. Fluoxetine is not known to decrease the effectiveness of valproic acid. The valproic acid level is not needed before beginning a short course of therapy with lorazepam.

A client with persistent, severe schizophrenia has been treated with phenothiazines. Now the client's speech is garbled as a result of rhythmic tongue protrusion. Which action will the nurse take first? Administer oral clonazepam. Obtain blood for laboratory testing. Reposition the client, and obtain an electrocardiogram. Obtain vital signs, and administer oxygen at 2 liters per nasal cannula.

Administer oral clonazepam. An adverse reaction to phenothiazines, tardive dyskinesia refers to choreiform tongue movements that are commonly irreversible and may interfere with speech. The priority action is to administer a benzodiazepine such as clonazepam to control the tardive dyskinesia. Repositioning and obtaining an electrocardiogram are not indicated with tardive dyskinesia. Obtaining vital signs may be helpful, but there is no indication the client is having an issue that would require supplemental oxygen. Obtaining blood for laboratory testing may be helpful to rule out thyroid dysfunction or polycythemia rubra vera; however, administering medication to treat the tardive dyskinesia is the priority.

A client is admitted after the police found the client sleeping in a car for three nights. The client says, "My spouse kicked me out and is divorcing me. It wasn't my fault I was fired from work. My spouse and boss are plotting against me because I'm smarter than they are." The client then pounds the table and says, "I'm not staying here, and you can't stop me." What should be included in the client's immediate plan of care? Select all that apply. Assault and escape precautions. Appropriate housing. Anxiety and anger management. collateral information from the spouse and boss Divorce counseling. Suspiciousness and grandiosity issues.

Anxiety and anger management. Assault and escape precautions. The client is showing increased anxiety and anger as well as refusing to stay in the hospital, which are immediate and crucial concerns at admission. The client is not likely to give permission to talk to the spouse and boss at this point. Housing issues and divorce counseling may be relevant before discharge, but not initially. Suspiciousness and grandiosity may be relevant after the client's anxiety and anger are under control.

A client is about to be discharged with a prescription for the antipsychotic agent haloperidol, 10 mg by mouth twice per day. During a discharge teaching session, a nurse should provide which instruction to the client? Increase the dosage up to 50 mg twice per day if signs of illness don't decrease. Apply a sunscreen before exposure to the sun. Take the medication 1 hour before a meal. Decrease the dosage if signs of illness decrease.

Apply a sunscreen before exposure to the sun. Because haloperidol can cause photosensitivity and precipitate severe sunburn, the nurse should instruct the client to apply a sunscreen before exposure to the sun. The nurse also should teach the client to take haloperidol with meals — not 1 hour before — and should instruct the client not to decrease or increase the dosage unless a physician orders the change.

A client with schizophrenia states "I can't stay here. I have to get away." The nurse observes that the client is very agitated. What should be the nurse's first action? Call for help from the other staff. Allow the client to express feelings. Ask the client to take lorazepam 1 mg orally. Approach the client in a calm, nonthreatening manner.

Approach the client in a calm, nonthreatening manner. Aggressive behavior occurs in stages from the triggering phase that starts the hostile response, to the escalation phase, to crisis, to recovery, and finally to post crisis. This client is in the triggering phase where the person is still able to see the situation and problem solve to a degree. The first action the nurse needs to do is to approach the client in a calm, nonthreatening manner. The nurse, however, needs to stay 6 feet away and avoid touching the person. This will show the client that the nurse is trustworthy. The client is still able to express feelings here so medication may or may not be needed. Calling for help will be done depending upon the client's response to the first action by the nurse.

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? Ignore the client because he appears to be hallucinating. Suggest the client spend some time in his room. Approach the client to interrupt the hallucinations. Remind the client that vulgar language is not appropriate in the hospital.

Approach the client to interrupt the hallucinations. The nurse intervenes with the client experiencing hallucinations to assist with increasing the client's awareness that the hallucinations are not part of reality but are a symptom of illness.The nurse does not ignore the client because the hallucinations can continue and escalate.Sending him to his room ignores the client's need, permits him to engage in his psychosis, increases confusion, and increases withdrawn behavior.Stating that vulgar language is not permissible ignores and dismisses the client.

A nurse is caring for a client with schizophrenia who experiences auditory hallucinations. The client appears to be listening to someone who isn't visible. The client gestures, shouts angrily, and stops shouting in mid-sentence. Which nursing intervention is appropriate? Ask the client to describe what the voices are saying while making it clear the nurse doesn't hear the voices. Approach and touch the client to get the client's attention. Ask another nurse to enter the room with you to be certain you are safe. Encourage the client to go to the client's room to experience fewer distractions.

Ask the client to describe what the voices are saying while making it clear the nurse doesn't hear the voices. By acknowledging that the client hears voices, the nurse conveys acceptance. By letting the client know that the nurse doesn't hear the voices, the nurse avoids reinforcing the client's hallucination. The nurse shouldn't touch a client with schizophrenia without advance warning. A hallucinating client may believe that the touch is a threat or act of aggression and respond violently. Being alone in the client's room encourages the client to withdraw and may promote more hallucinations. The nurse should focus on the client's feelings and the client's safety.

Police bring a client to the emergency department after she threatens to kill her ex-husband. The client states emphatically, "The police should bring him in, not me. He is paranoid about my dating and has been stalking me for weeks. He is probably off his medicines. His case manager and the police will not do anything." In what order should the following nursing actions be done from first to last? All options must be used.

Assess the client's risk for harm to self and others. Interview the client about her current needs and situation. Obtain the name of her ex-husband's case manager. Ask about the marital problems leading to the divorce. The nurse should first assess the client's risk for harm, especially because the client could direct her anger toward her ex-husband or the nurse. Then it is important to know more about her current situation and her immediate needs. Obtaining information from the ex-husband's case manager might help clarify the risk of harm to the client. Problems leading to the divorce are less important than the situation following the divorce.

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? Evaluate the family's understanding of the schizophrenia diagnosis. Administer prescribed antipsychotic medications. Clearly define the unit rules with the client and family. Assess the client's risk for suicide, homicide, or other violent behavior.

Assess the client's risk for suicide, homicide, or other violent behavior. Schizophrenia is characterized by suspiciousness, anxiety, and hallucinations. These symptoms put the client with schizophrenia at risk for violence toward self or others. The only assessment data in the stem state the client is agitated, so more assessment is required by the nurse before an intervention is necessary. Administering antipsychotic medications, evaluating the family's understanding of the diagnosis, and describing the unit rules are important, but each should be addressed after the safety of the client and those around the client has been established.

Which instructions should the nurse include when teaching a client about quetiapine therapy? Select all that apply. Avoid becoming overheated or dehydrated during therapy. Contact the prescriber before taking over-the-counter preparations. Have an annual eye examination to check for cataract formation. Change positions slowly to prevent orthostatic hypotension. Report dry mouth immediately.

Avoid becoming overheated or dehydrated during therapy. Change positions slowly to prevent orthostatic hypotension. Contact the prescriber before taking over-the-counter preparations. The nurse should instruct the client to avoid becoming overheated or dehydrated during therapy to prevent neuroleptic malignant syndrome. The nurse also should tell the client to contact the prescriber before taking over-the-counter preparations and to change positions slowly to prevent orthostatic hypotension. The client should have an eye examination every 6 months to check for cataract formation. Dry mouth is a common adverse effect of therapy that can be alleviated with ice chips, drinks, or sugarless hard candy; this effect does not need to be reported immediately.

A client with paranoid schizophrenia is recently admitted to the psychiatric unit. The client is hesitant to eat the food provided and states "I know they poisoned this food before putting it on my plate." What is the priority nursing action? Bring the client food in unopened containers. Request a cannabinoid appetite enhance from the provider. Ask the client which poison is inside the food. Have the family bring in the client's favorite food.

Bring the client food in unopened containers. Clients with paranoid schizophrenia are often concerned about the safety of their food. Bringing the client food in unopened containers may ease this paranoia. Because the client was recently admitted to the unit, requesting an appetite enhancer from the health care provider is not the priority action at this time. The nurse should attempt other strategies first. Having the family bring in food is passing the buck. The nurse should seek out strategies to help this client situation. Asking the client which poison is in the food is exploring the paranoia, which is not an appropriate nursing action.

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." Stand in the doorway and say, "I'll have to put you in restraints if you don't stop that." Call the operator and page the emergency response team immediately to the unit. Approach the client calmly and say, "You need to write your feelings down in your journal."

Calmly walk over to the client and say, "Tell me what's going on." Asking the client to tell the nurse what is going on encourages the client to discuss altered perceptions rather than feel guilt or shame, while supporting the client with your presence. Approaching the client to encourage journal writing is incorrect because clients experiencing psychosis have difficulty following abstract instructions and focusing attention. Calling the operator and paging the emergency response team immediately to the unit is incorrect because the client is not exhibiting violence toward others and verbal de-escalation techniques have not been tried first. Standing in the doorway and saying, "I'll have to put you in restraints if you don't stop that," is threatening to punish the client rather than helping the client gain control of their behaviors.

A nurse is caring for a client receiving a dopamine receptor agonist for treatment of extrapyramidal symptoms caused by antipsychotic medications. What evaluation would indicate a therapeutic response to this drug? Client experiences a decrease in dystonia. Client exhibits bradyphrenia during the nursing assessment. Client exhibits akathisia only while sitting. Client exhibits a shuffling gait with stooped posture.

Client experiences a decrease in dystonia. Extrapyramidal effects and antipsychotic-induced muscle rigidity are caused by a low level of dopamine. Dopamine receptor agonists reduce extrapyramidal symptoms such as bradyphrenia or slowed thought processes, akathisia or meaningless movements such as marching in place, or dystonia or abnormal muscle rigidity or movements.

The nurse is performing an assessment of a client admitted to the behavioral health unit with schizophrenia. Which behavior by the client would the nurse document as positive symptoms? Select all that apply. Client states, "I am the King of England!" Client is copying the movements of the client sitting next to them. Client is sitting in the corner without expression or movement. Client states, "Do you see all of the rats crawling on the floor? Kill them!" Client is unable to speak.

Client states, "I am the King of England!" Client is copying the movements of the client sitting next to them. Client states, "Do you see all of the rats crawling on the floor? Kill them!" The positive symptoms of schizophrenia include delusions or false beliefs that are not based in reality, echopraxia is an imitation of the movements and gestures of another person whom the client is watching. Hallucinations are common positive symptoms or perceptual experiences that have no basis in reality. Negative symptoms are alogia and catatonia.

A client whose symptoms of schizophrenia are under control with olanzapine, and who is functioning at home and in part-time employment, reports being very concerned about gaining 20 lb (9.1-kg) since starting the medication 6 months ago. What should the nurse do? Tell the client not to worry, because the weight gain will stop. Discuss nutrition, daily diet, and exercise with the client. Suggest that the client talk to the health care provider about changing to another antipsychotic. Advise the client to decrease the dosage by one-half.

Discuss nutrition, daily diet, and exercise with the client. The nurse should discuss nutrition, daily diet, and exercise with the client concerned about weight gain while taking olanzapine. Weight gain is common with this drug therapy. The client would benefit from nutrition and exercise teaching, and the nurse should provide the client with an initial course of action. Suggesting that the client talk with the health care provider about changing to another antipsychotic may not be in the client's best interest. Olanzapine is keeping the symptoms of illness under control, and the client is able to function at home and on the job. Advising the client to cut the dose in half may lead to decompensation and is outside the nurse's scope of practice. Telling the client not to worry because the weight gain will stop minimizes the client's concern. Also, additional weight gain is possible.

The client diagnosed with borderline personality disorder who is to be discharged soon threatens to "do something" to herself if discharged. What should the nurse do first? Discuss the meaning of the client's statement with her. Ask a family member to stay with the client at home temporarily. Ignore the client's statement because it is a sign of manipulation. Request that the client's discharge be canceled.

Discuss the meaning of the client's statement with her. Any suicidal statement must be assessed by the nurse. The nurse should discuss the client's statement with her to determine its meaning in terms of suicide, overwhelming feelings of anxiety, abandonment, or other need that the client cannot express appropriately. It is not uncommon for a client with borderline personality disorder to make threatening comments before discharge. Extending the hospital stay is inappropriate because it would encourage dependency and manipulation. Ignoring the client's statement on the assumption that it is a sign of manipulation is an error in judgment. Asking a family member to stay with the client temporarily at home is not appropriate and places the responsibility for the client on the family instead of the client.

A client is admitted to the psychiatric emergency department with difficulty sleeping, poor judgment, and incoherent speech. The client reports being a special messenger from the Messiah who needs to be "sacrificed to save the world." Which action should the nurse take first? Institute suicide precautions. Ask a family member to stay with the client. Administer an oral antipsychotic. Encourage the client to describe the suicide plan.

Encourage the client to describe the suicide plan. Delusions of grandeur are common symptoms of the manic phase of bipolar disorder. The priority nursing action is to maintain client safety and institute suicide precautions. Administering an antipsychotic and asking about the suicide plan are acceptable nursing actions, but first the nurse must ensure client safety. Asking a family member to sit with the client inappropriately delegates responsibility to someone else; the nurse must address the issue of client safety immediately.

A client is in the withdrawn phase of catatonia due to schizophrenia. This is the client's first admission to an early psychosis program at an urban hospital. At present, the client is completely stuporous. What is the priority while giving care to the client during this phase of symptoms? Provide as much sensory stimulation as possible using conversation, radio, and television. Ask the client to do exactly the opposite of what is desired. Maintain a quiet atmosphere, speaking as little as possible to the client. Explain all physical care activities in simple, explicit terms as though expecting a response.

Explain all physical care activities in simple, explicit terms as though expecting a response. A client in a stuporous state is not in a position to negotiate, discuss, or gather insight. At this stage of a psychotic experience, a client requires clear and simple explanations of all activities. Not speaking much would be confusing and increase anxiety, but excessive information and stimuli would also not benefit goal-directed activities.

A client's admitting diagnosis is schizophrenia with an episodic delusional disorder. The nurse applies what intervention strategy while working with the client in this pronounced delusional state? Attempt to define and reinforce positive aspects of the client's personality. Address the client within a group so others may speak to the irrational delusion. Focus on the client's underlying feelings, and redirect inappropriate responses. Discuss the consequences of responding to the delusional thoughts with the client.

Focus on the client's underlying feelings, and redirect inappropriate responses. The work of the nurse is to support the client's feelings and potential behaviors (for example, anxiety and restlessness) while offering coping techniques for these feelings. The nurse avoids exploring or trying to understand the delusions themselves. The goal of treating a delusional disorder is to increase client awareness of the delusion and to acknowledge the feelings the delusions places on the client. Reinforcing the positive aspects of the client's personality does not help achieve this goal. One-on-one therapy is better than group therapy for establishing trust with a client experiencing delusions.

What should the nurse do when the client with a diagnosis of schizophrenia walks into group naked? Instruct the client to go to his room and to put on some clothes. Wrap a blanket around him and tell him to be seated for the remainder of group. Ask a male client to take off his sweater and wrap it around the client's waist. Lead the client to his room and help him dress if he needs assistance.

Lead the client to his room and help him dress if he needs assistance. The best nursing action is to lead the client to his room and assist him with putting on his clothes. The client with disorganized behavior needs the nurse's assistance to protect his self-esteem and dignity and to avoid embarrassment. Instructing the client to go to his room to put on his clothes may not be effective because the client may be too disorganized to follow directions. Wrapping a blanket around the client is helpful. Instructing him to be seated for the remainder of group is inappropriate and demeaning. Asking another client to remove his sweater and wrap it around the other client's waist is inappropriate.

The director of an outpatient rehab program tells the nurse that the client with schizophrenia had done well for 6 months until last week, when a new person started the program. This new person worked faster than the client did and took his place as leader of the group. Based on this information, which intervention is most appropriate? Ask the director to assign the client to another group when he returns to the program. Make a home visit, and tell the client that if he does not return to the program, he will lose his place there. Make an appointment to meet the client at the mental health center, and ask him about the situation. Arrange for the placement of the client in a skill-training program.

Make an appointment to meet the client at the mental health center, and ask him about the situation. The most therapeutic action at this time is for the nurse to make an appointment with the client at the mental health center to explore his feelings and behavior. Doing so acknowledges the client's importance and makes him a partner in resolving the problem. The nurse needs to determine what is going on in the situation first, and then plan accordingly. Threatening the client with loss of the position, asking for a new assignment for the client, or arranging for the placement of the client in a skill-training program is inappropriate and premature.

A nurse is caring for a client who recently starting taking haloperidol. Which client assessment would be a priority for nurse follow up? Frequent day naps Neck stiffness with head tilt Elevated liver function tests Dry mouth with nausea

Neck stiffness with head tilt An antipsychotic agent like haloperidol can cause acute dystonic reactions such as muscle spasms in the neck, face, tongue, back, and legs, as well as torticollis. Torticollis is neck stiffness that causes the head to tilt to one side with the chin pointing in the opposite direction. This adverse reaction requires prompt follow up by the nurse as early detection of dystonic reactions can minimize complications. Elevated liver function tests, dry mouth, and nausea are common adverse reactions that require follow up; however, they are not priority. Although haloperidol is one of the least sedating antipsychotics, drowsiness and dizziness are common side effects and usually subside after a few weeks.

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? Encourage the use of saline mouth rinses until the sore throat is gone. Obtain an order for the client to have a white blood cell count drawn. Suggest that the client drink warm beverages and rest. Have the client decrease the daily amount of clozapine by half.

Obtain an order for the client to have a white blood cell count drawn. The report of a sore throat may indicate an infection caused by agranulocytosis, a depletion in white blood cells. The way to determine this is by obtaining a white blood cell count. The other options do not get to the cause of the client's concern.

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? Arrange for the client to be admitted to a psychiatric hospital for a short stay. Check with the client's employer about her work performance. Remind the client that hearing voices is a symptom of her illness that she can cope with. Obtain information about the client's medication compliance.

Obtain information about the client's medication compliance. Symptom exacerbation is most often related to noncompliance with the prescribed medication regimen. Therefore, obtaining information about the client's compliance is the first priority. Helping the client recognize the symptoms and her ability to manage them is appropriate, but this is not the first priority. Checking with her employer is not appropriate and does not help the client with management of her illness. Hospitalization is not indicated because the client is still working and can talk about the symptoms.

A nurse is caring for a client who is in a catatonic state due to schizophrenia. Which nursing intervention would be most important in the care of this client? Predict and fulfill client needs until the client is more active. Attempt to engage the client in therapeutic conversations with members of the staff and other clients. Reorient the client as often as is required. Assess the level of family functioning and availability of support systems.

Predict and fulfill client needs until the client is more active. A client in a stuporous state may refuse to eat or drink, which can interfere with life functioning. Although engagement in communication, reorientation to reality, and family functioning are all important concerns, the priority for nursing care is to assess and intervene if the client refuses to eat and drink. Higher levels of care may be required, and it is a priority for the nurse to assess this state.

A client with a diagnosis of schizophrenia spectrum disorder is admitted to the inpatient unit after developing water intoxication. Once the client is medically stable and no longer exhibiting the behavior of seeking water, which nursing interventions are appropriate at this time? Select all that apply. Maintain a structured environment. Lock the unit's kitchen and bathroom. Medicate the client at night. Weigh the client every day. Monitor the client's intake and output. Provide gum for the client.

Provide gum for the client. Weigh the client every day. Monitor the client's intake and output. Maintain a structured environment. Water intoxication is a potentially fatal disturbance in brain functions that results when the normal balance of electrolytes is outside of safe limits by overhydration. It is appropriate for the nurse to monitor intake and output, weigh the client daily, and encourage the client to chew gum rather than drink water. The nurse also provides a structured environment as a way to distract and divert the client away from obtaining fluids. Medicating the client at night and locking the unit's kitchen and bathroom would not be necessary at this time.

The nurse is monitoring a client who appears to be hallucinating. The client displays paranoid speech content, seems agitated, and gestures at a figure on the television. Which nursing interventions are appropriate? Select all that apply. Instruct other team members to ignore the client's behavior. Reinforce that the client is not in any danger. Acknowledge the presence of the hallucinations. Use a calm voice and simple commands. Delegate client assessment to a licensed practical/vocational nurse In a firm voice, instruct the client to stop the behavior.

Reinforce that the client is not in any danger. Acknowledge the presence of the hallucinations. Use a calm voice and simple commands. Hallucinations are false or distorted sensory perceptions that appear to be real. Using a calm voice and giving simple commands, the nurse would reassure the client of safety. The nurse would not challenge the client; rather, the nurse would acknowledge the hallucinatory experience. It is not appropriate to ask the client to stop the behavior. Ignoring behavior will not reduce the client's agitation. During an acute episode of hallucinations, it is not appropriate to delegate skilled assessment.

Which information is important for a nurse to include in a teaching plan for a client with schizophrenia who is taking clozapine? Report a sore throat or fever to the physician immediately. Blood pressure must be monitored for hypertension. Monthly blood tests will be necessary. Stop the medication when symptoms subside.

Report a sore throat or fever to the physician immediately. A sore throat and fever are indications of an infection caused by agranulocytosis, a potentially life-threatening complication of clozapine therapy. Because of the risk of agranulocytosis, white blood cell (WBC) counts are necessary weekly, not monthly. If the client's WBC count drops below 3,000/μl, the medication must be discontinued. Clients taking this medication may experience hypotension. Warn the client to stand up slowly to avoid dizziness from orthostatic hypotension. The client should continue to take this medication even after symptoms have been controlled. If the medication must be discontinued, it should be slowly tapered over 1 to 2 weeks under the supervision of a physician.

When assessing a hospitalized client diagnosed with major depression and borderline personality disorder, the nurse should ask the client about which of the following first? Suicidal thoughts. Access to pills and weapons. Suicidal plans. Seriousness of the client's intent to die.

Suicidal thoughts. The nurse should first determine if the client is suicidal. If the client is suicidal, it is crucial to know what the client plans to do. The seriousness of intent to die would determine the level of suicidal precautions required to maintain safety. Understanding about access to means for suicide is more important as the client is preparing for discharge.

A 23-year-old client diagnosed with schizophrenia cheerfully announces, "My mom and I are so excited that I'm pregnant. She's willing to help us take care of the baby too." Which reason should cause the nurse to be concerned about this situation? The client did not say that the father of the baby was excited about this. The mother is not likely to provide enough help for what the client needs. The client will have difficulty financially supporting the baby. Symptom management will be difficult in early pregnancy without medications.

Symptom management will be difficult in early pregnancy without medications. Because antipsychotic agents cross the placental barrier and can be teratogenic, they are to be avoided during pregnancy, especially during the first trimester. Later in the pregnancy, low doses of medications may be given if necessary. Although the degree of excitement by the father, the mother's ability to provide help, and the client's financial situation may or may not be of concern, the priority in this situation is the safety of the fetus and risks associated with the need for antipsychotic therapy.

The nurse hands the medication cup to a client who is psychotic and exhibiting concrete thinking, and tells the client to take his medicine. The client takes the cup, holds it in his hand, and stares at it. What should the nurse do next? Tell the client to put the medicine in his mouth and swallow it with some water. Ask another staff member to stay with the client until he takes the medication. Instruct the client to sit in the dayroom and wait for the nurse to assist him. Say nothing and wait for the client to put the medication in his mouth and swallow it.

Tell the client to put the medicine in his mouth and swallow it with some water. The nurse instructs the client clearly and directly to put the medication in the mouth and then to swallow it with some water. Clear, step-by-step directions assist the client to process what the nurse is saying. Telling the client to sit in the dayroom and wait, asking another staff member to stay with the client, or saying nothing is not helpful.

For the client with catatonic behaviors, which outcome would indicate a medication has been most effective in improving long-term behavior? The client can move all extremities occasionally. The client walks with the nurse to the client's room. The client responds to verbal directions to eat. The client initiates simple activities without directions.

The client initiates simple activities without directions. Although all the actions indicate improvement, the ability to initiate simple activities without directions indicates the most improvement in the catatonic behaviors. Moving all extremities occasionally, walking with the nurse to the client's room, and responding to verbal directions to eat represent single steps toward the client initiating the client's own actions.

A client was admitted to the behavioral health unit with a diagnosis of severe depression. The client was started on bupropion. Forty-eight hours after initiating the drug therapy, the client has recovered from depression, is laughing, singing, and dancing in the hallway and in the sitting room. How should the nurse interpret this behavior? These are unusual side effects of the medication. The medication is therapeutic. The client is acting this way so that they can be discharged. The client is most likely bipolar rather than depressed, and the healthcare provider should be notified of the behavior.

The client is most likely bipolar rather than depressed, and the healthcare provider should be notified of the behavior. This behavior is often seen in clients who are bipolar when placed on an antidepressant. A mood stabilizer, such as lithium or lamotrigine, is needed to balance emotional states. The medication has affected the depression, but the client is bipolar and needs a mood stabilizer instead. These side effects occur in a person who is bipolar rather than someone suffering from depression.

A nurse is caring for a client with schizophrenia. Which outcome requires revising the client's care plan? The client demonstrates the ability to meet self-care needs. The client doesn't harm self or others. The client doesn't engage in delusional thinking. The client spends more time alone.

The client spends more time alone. The client with schizophrenia is commonly socially isolated and withdrawn; therefore, having the client spend more time alone wouldn't be a desirable outcome. Rather, a desirable outcome would specify that the client spend more time with other clients and staff on the unit. Delusions are false personal beliefs. Reducing or eliminating delusional thinking through use of talking therapy and antipsychotic medications would be a desirable outcome. Protecting the client and others from harm is a desirable client outcome achieved through close observation, removal of any dangerous objects, and medication administration. Because the client with schizophrenia may have difficulty meeting self-care needs, fostering the ability to independently perform self-care is a desirable client outcome.

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 be able to problem solve in situations on the psychiatric unit. The client will be free from anxiety and be able to use self-calming techniques before reaching panic level. The client will show no self-harm or harm to staff. The client will be oriented to person, place, and time.

The client will show no self-harm or harm to staff. The client is at increased risk for injury because of their hyperactivity, agitation, and disorientation. The goal for no self-harm or harm to staff best fits the priority for this situation. Although the client's anxiety and orientation is a concern and is important for the client's care, the client's safety always takes highest priority. The nurse should plan first and foremost to prevent injury and harm for which the client is at risk given their current condition.

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)? sodium level of 136 mEq/L (136 mmol/L) hemoglobin of 11.9 g/dl (119 g/L) hyaline casts in the urinalysis WBC of 3,500

WBC of 3,500 A side effect of clozapine is leukopenia. A WBC count is drawn every week and if it starts to drop, the HCP is notified. Slightly low hemoglobin levels or a normal sodium level are not significant. Hyaline casts occur because of protein in the urine, and a small amount is normally found in the urine, especially after exercise.

A nurse caring for a client diagnosed with schizophrenia should perform which intervention when the client becomes suspicious and refuses to take their medication? Tell the client they must take the medication now, Attempt to coax the client into taking the medication by calling them "Honey." Wait for a short time and then attempt to administer the medication Document that the client is noncompliant

Wait for a short time and then attempt to administer the medication A flexible care plan is needed for any client who behaves in a suspicious, withdrawn, or regressed manner or who has a thought disorder. Because such a client communicates at different levels and at different times and is sometimes in control of self, the nurse must be able to adjust nursing care as the situation warrants, such as offering the medication again after waiting for a short period of time. Forcing the client to take the medication now and calling the client "Honey" may anger the client.

A nurse is assessing a client who is receiving clozapine. The nurse reviews the chart. What should the nurse do next? Withhold the clozapine, and notify the primary care provider. Administer the clozapine, and notify the physician. Give the clozapine, and tell the client to lie down. Withhold the clozapine, and tell the client to go to an exercise group.

Withhold the clozapine, and notify the primary care provider. Because clozapine can cause tachycardia, the nurse should withhold the medication if the pulse rate is greater than 140 bpm and notify the physician. Giving the drug or telling the client to exercise could be detrimental to the client.

A client with a tentative diagnosis of psychosis is admitted to the psychiatric unit. A physician orders the phenothiazine thioridazine 50 mg by mouth three times per day. Phenothiazines differ from central nervous system (CNS) depressants in their sedative effects by producing: more prolonged sedative effects, making the client more difficult to arouse. greater sedation than CNS depressants. a calming effect from which the client is easily aroused. deeper sleep than CNS depressants.

a calming effect from which the client is easily aroused. Shortly after phenothiazine administration, a quieting and calming effect occurs, but the client is easily aroused, alert, and responsive and has good motor coordination.

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. structural and neurobiological factors. genetic factors leading to a faulty dopamine receptor. environmental factors and childhood trauma.

a combination of biological, psychologic, and environmental factors. A combination of biological, psychologic, and environmental factors is thought to cause schizophrenia. Studies of twins and adopted siblings have strongly implicated a genetic predisposition for schizophrenia; however, a reliable genetic marker has not been determined. Excessive dopamine activity in the brain has also been suggested as a causal factor. Communication and the family system have been studied as contributing factors in the development of schizophrenia.

A client with schizophrenia hears a voice saying the client is evil and must die. The nurse understands that this client is experiencing: flight of ideas. a hallucination. a delusion. ideas of reference.

a hallucination. A hallucination is a sensory perception, such as hearing voices and seeing objects, that only the client experiences. A delusion is a false belief. Flight of ideas refers to a speech pattern in which a client skips from one unrelated subject to another. Ideas of reference refers to the mistaken belief that someone or something outside the client is controlling the client's ideas or behavior.

The nurse is planning care for a client who has been experiencing a manic episode for 6 days and is unable to sit still long enough to eat meals. Which choice will best meet the client's nutritional needs at this time? a bowl of vegetable soup a green salad topped with chicken pieces favorite foods from home a peanut butter sandwich

a peanut butter sandwich Giving the client finger foods that have protein, carbohydrates, and calories supplies energy and allows the client to eat while on the move. A salad or soup is very difficult for the client to eat while moving and may not supply the nutrients needed. Favorite foods from home may or may not be appropriate to eat while walking.

A client who was prescribed clozapine 2 months ago arrives in the clinic and informs the nurse that the they have been feeling extremely fatigued and feverish and has a sore throat. The nurse observes that the client has two small ulcerations of the oropharynx. Which does the nurse suspect may be occurring with this client? thiamine deficiency tardive dyskinesia dystonic reaction agranulocytosis

agranulocytosis Clozapine has a potential side effect of agranulocytosis, which can develop suddenly or over a period of time. It is characterized by fever, malaise, a sore throat with ulcerations, and leukopenia. The drug must be immediately discontinued. It is important for the client to have weekly blood counts for 6 months of therapy and then every 2 weeks. Thiamine deficiency is exhibited by shortness of breath and other symptoms of congestive heart failure. Tardive dyskinesia is a side effect of antipsychotic medications and is characterized by lip smacking, tongue protrusion, chewing, blinking, grimacing, and choreiform movements of the limbs and feet. Dystonic reactions are an extrapyramidal side effect characterized by spasms in several muscle groups.

After 3 days of taking haloperidol , the client shows an inability to sit still, is restless and fidgety, and paces around the unit. The client is showing signs of which extrapyramidal adverse reactions? tardive dyskinesia dystonia parkinsonism akathisia

akathisia The client's behavior is best defined as akathisia, or motor restlessness, and a compulsion to move constantly.Dystonia is characterized by uncoordinated spasmodic movements.Parkinsonism is characterized by decreased mobility, muscle rigidity, and tremors.Tardive dyskinesia is characterized by twitching or involuntary muscular movement.

A client receiving fluphenazine decanoate develops bradykinesia, speech changes, and a tremor. The nurse would be correct to anticipate administering which drug(s) to control this extrapyramidal effect? Select all that apply. diphenhydramine benztropine amantadine lithium phenytoin

amantadine benztropine diphenhydramine Fluphenazine decanoate is an antipsychotic that may cause pseudoparkinsonism. Antiparkinsonian agents such as amantadine and benztropine help control these symptoms. An antihistamine like diphenhydramine may be used to control tremors. Phenytoin is used to treat seizure activity, and lithium is a mood stabilizer.

After 10 days of lithium therapy, the client's lithium level is 1.0. How does the nurse interpret this value? an atypical client response to the drug a laboratory error a toxic level an anticipated therapeutic blood level of the drug

an anticipated therapeutic blood level of the drug The therapeutic blood level range for lithium is between 0.6 and 1.2 for adults. A level of 1.0 can be anticipated after 10 days of treatment. Lithium toxicity occurs at levels above 1.5.While laboratory error can occur, that possibility would be more plausible if the level were extremely high or low.An atypical response would be manifested as an unusual physical or psychological response, not through blood levels.

During a home visit, the nurse discovers that the client is less verbal, less active, less responsive to directions, severely anxious, and more dazed. The nurse interprets these findings to indicate that the client needs which intervention? a sleep aid an immediate medical evaluation an increase in medication a clinic appointment

an immediate medical evaluation The client is exhibiting symptoms of becoming catatonic and unable to care for himself and needs immediate evaluation and possible hospitalization. A sleep aid is not sufficient to treat this client. The client's worsening condition dictates action without waiting for a clinic appointment. An increase in medication may be indicated, but hospitalization is required first for safety.

A client diagnosed with schizophrenia is brought to the hospital from a group home where he became agitated, threw a chair at another client, and has been refusing medication for 8 weeks. The client exhibits a flat affect, is not caring for his hygiene, and has become increasingly withdrawn and asocial. The health care provider prescribes treatment with risperidone to improve the client's negative and positive symptoms of schizophrenia. When evaluating the drug's effectiveness on the client's negative symptoms, the nurse should expect improvement in which symptom? apathy, affect, social isolation hostility, ideas of reference, tangential speech aggression, bizarre behavior, illusions agitation, delusions, hallucinations

apathy, affect, social isolation When determining the effectiveness of risperidone, the nurse would expect improvement in the client's negative symptoms of apathy, flat affect, and social withdrawal. Delusions, hallucinations, illusions, and ideas of reference are positive symptoms of schizophrenia. Agitation, hostility, and aggression are also the result of the positive symptoms.

A client with schizophrenia tells the nurse that he does not go out much because he does not have anywhere to go and he does not know anyone in the apartment where he is staying. Which action is most beneficial for the client at this time? arranging for the client to attend day treatment at the clinic making an appointment for the client to see the nurse daily for 2 weeks thinking about the need for rehospitalization for the client encouraging him to call his family to visit more often

arranging for the client to attend day treatment at the clinic Because the client can live in an apartment setting, further development of independent functioning and the skills to gain as much independence as he is capable of need to be fostered, including getting out and developing new friendships. Arranging for participation in day treatment is most beneficial at this time. Family visits and daily nursing visits do not encourage the client to do this. Making an appointment for 2 weeks later puts the client's needs off. Lack of social relationships is not a sufficient reason for rehospitalization.

A client in a catatonic state is admitted to the inpatient unit. The client is emaciated, stares blankly into space, and does not respond to verbal or tactile stimuli. Which nursing intervention is a priority? assessing the client's nutritional and hydration status providing a safe and supportive environment for the client orientating the client to the unit and immediate surroundings for safety providing therapeutic communication and emotional stimulation

assessing the client's nutritional and hydration status Priority is placed on immediate physical needs over psychosocial needs. In this situation, nutritional needs are the priority for a client in a catatonic state. Providing therapeutic communication, emotional stimulation, and a safe, nurturing, supportive environment and orienting the client to the environment are all appropriate actions, but the client's immediate physical needs must be met first.

What is the most appropriate long-term goal for an outpatient client with schizophrenia who has been withdrawn from friends and family for 3 weeks? remaining out of bed for 10 hours a day allowing two friends to visit every day attending day therapy three times a week calling the client's mother once a day

attending day therapy three times a week Attending day therapy three times per week is a long-term goal that will show the most progress in overcoming withdrawal. The client's calling his mother is a first step in getting out of a severe withdrawal. Allowing two friends to visit every day would be appropriate if the client is successful with calling his mother once a day. Insufficient information is presented in the scenario to indicate that excessive sleep is a problem.

While the nurse is performing an admission assessment, the client stops talking in the middle of a sentence, tips his head to the side, and listens carefully. The nurse recognizes that the client most likely experiencing which problem? auditory hallucinations delusions of reference somatic delusions pseudoparkinsonism

auditory hallucinations When the client is listening to the voices, it is most likely an auditory hallucination. Somatic delusions are false beliefs about the functioning of the client's own body. Pseudoparkinsonism is another name for the extrapyramidal symptoms of the medications. Delusions of reference involve events within the environment.

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? perseveration tangential word salad avolition

avolition Avolition refers to impairment in the ability to initiate goal-directed activity. Word salad is a behavior in which a group of words are put together in a random fashion without logical connection. A person exhibiting tangential behavior never gets to the point of the communication. In perseveration, a person repeats the same word or idea in response to different questions.

The nurse is facilitating a group of clients with schizophrenia when one client says, "I like to drive my car, bar, tar, far." This client is exhibiting: clang association. echopraxia. echolalia. neologisms

clang association. Linking words together based on their sounds rather than their meanings is called clang association. Echolalia is the involuntary parrot-like repetition of words spoken by others. Echopraxia refers to meaningless imitation of others' motions. Neologisms are words that a person invents.

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? depression dehydration dementia delirium

delirium Based on CAM's assessment tool, the client has an acute onset of behaviors, is inattentive, has disorganized thinking, and is lethargic (decreased level of consciousness). This cluster of behaviors constitutes delirium. Dementia has a slow onset, the client's level of consciousness is usually normal, and the client can focus attention. Clients who are depressed are alert and oriented and able to focus attention, although they may be easily distracted. Further assessment is needed to determine if the client also is dehydrated.

A client with chronic schizophrenia receives 20 mg of fluphenazine decanoate by I.M. injection. Three days later, muscle contractions that contort the client's neck. This client is exhibiting which extrapyramidal reaction? akinesia akathisia dystonia tardive dyskinesia

dystonia Dystonia, a common extrapyramidal reaction to fluphenazine decanoate, manifests as muscle spasms in the tongue, face, neck, back, and sometimes the legs. Akinesia refers to decreased or absent movement; akathisia, to restlessness or inability to sit still; and tardive dyskinesia, to abnormal muscle movements, particularly around the mouth.

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? discussing with the client how to prevent relapse acknowledging the client's strengths and accomplishments engaging the client in reality-based conversations encouraging the client to engage in one-on-one therapeutic conversations

engaging the client in reality-based conversations Although encouraging therapeutic conversations, discussing relapse prevention, and acknowledging the client's strengths are all important with a client experiencing hallucinations, engaging in reality orientation is the first priority for the nursing care of this client.

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 unresolved symptom of schizophrenia unusual reaction to clozapine delusion, requiring further assessment

expected adverse effect of clozapine Excessive salivation, or sialorrhea, is commonly associated with clozapine therapy. The client can use a washcloth to wipe the saliva instead of spitting. It is an expected adverse effect of the drug, not a delusion, an unusual reaction, or an unresolved symptom of schizophrenia.

When caring for a client receiving haloperidol, the nurse should assess for which problem? oversedation hypersalivation orthostasis extrapyramidal symptoms

extrapyramidal symptoms Haloperidol, a traditional antipsychotic drug, is associated with a high rate of extrapyramidal adverse effects.At therapeutic dosages, haloperidol is associated with a low incidence of sedation and orthostasis.Hypersalivation is an adverse effect of clozapine.

A client with bipolar disorder, manic phase, just sat down to watch television in the lounge. As the nurse approaches the lounge area, the client states, "The sun is shining. Where is my son? I love Lucy. Let's play ball." The client is displaying which condition? depersonalization concreteness flight of ideas use of neologisms

flight of ideas The client is demonstrating flight of ideas, or the rapid, unconnected, and often illogical progression from one topic to another. Concreteness involves interpreting another person's words literally. Depersonalization refers to feelings of strangeness concerning the environment or the self. A neologism is a word made up by a client.

A client begins clozapine therapy after several other antipsychotic agents fail to relieve psychotic symptoms. The nurse instructs the client to return for weekly white blood cell (WBC) counts to assess for which adverse reaction? systemic dermatitis hepatitis infection granulocytopenia

granulocytopenia Clozapine can cause life-threatening neutropenia or granulocytopenia. To detect this adverse reaction, a WBC count should be performed weekly. Hepatitis, infection, and systemic dermatitis aren't adverse reactions to clozapine therapy.

A client with schizophrenia is admitted to the psychiatric unit of a local hospital. During the next several days, the client is seen laughing, yelling, and talking out loud to no one. This behavior is characteristic of: delusion. looseness of association. hallucination. illusion.

hallucination. Auditory hallucination, in which one hears voices when no external stimuli exist, is common in schizophrenic clients. Such behaviors as laughing, yelling, and talking to oneself suggest such a hallucination. Delusions, also common in schizophrenia, are false beliefs or ideas that arise without external stimuli. Clients with schizophrenia may exhibit looseness of association, a pattern of thinking and communicating in which ideas aren't clearly linked to one another. Illusion is a less severe perceptual disturbance in which the client misinterprets actual external stimuli. Illusions are rarely associated with schizophrenia.

A charge nurse is educating a new nurse on antipsychotic medications. The charge nurse knows teaching has been effective when the new nurse makes which statement? "Antipsychotic medication blocks the effect of acetylcholine at the myoneural junction." "Antipsychotic medication depresses the central nervous system by blocking the postsynaptic transmission of dopamine, serotonin, and norepinephrine." "Antipsychotic medication binds to opiate receptors in the central nervous system and alters the response to pain." "Antipsychotic medication stops the breakdown of monoamine neurotransmitters, which keep the brain's concentration of neurotransmitters steady."

"Antipsychotic medication depresses the central nervous system by blocking the postsynaptic transmission of dopamine, serotonin, and norepinephrine." Antipsychotic medications, also known as neuroleptic medications, work by blocking the transmission of dopamine and the reuptake of norepinephrine and serotonin. Monoamine oxidase inhibitor antidepressants work by stopping the breakdown of monoamine neurotransmitters. Neuromuscular-blocking agents block the effect of acetylcholine at the myoneural junction, and opioids bind to receptors and alter the pain response.

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? "I need you to trust me and the staff members in the facility." "It sounds like you are not concerned about your problems and why you are in the hospital." "Anything you say about your feelings is confidential but your care involves the whole team so we can all work together." "This can just be between us, and I will share your progress only with the doctors and not your family."

"Anything you say about your feelings is confidential but your care involves the whole team so we can all work together." Being truthful with the client and reinforcing the need for prevention of harm to self or others clarifies what the client can expect from the team. Challenging the client will contribute to a sense of low self-worth. "It sounds like you are not concerned about your problems and why you are in the hospital" is nontherapeutic and devalues the client's self-perception. Negotiating a special agreement or luring the client into the interview will not be therapeutic. "I need you to trust me and the staff members in the facility" does not offer a therapeutic way to establish trust.

A nurse is caring for a client with schizophrenia who states, "I can't handle the voices anymore! It's over! I've done all I can." Which statement by the nurse is best? "Have you felt like this before?" "Are you thinking of hurting yourself?" "Have you been taking your medications?" "What do you mean by that statement?"

"Are you thinking of hurting yourself?" Risk of suicide is greater in patients with a serious illness, including mental or emotional disorders. The nurse should recognize the client's statement as a warning for possible self-harm. With this concern, the nurse should ask the client a yes/no question regarding self-harm. Using an open-ended question is therapeutic, but assessing the risk of self-harm requires a more direct approach. Asking about medications or past feelings should wait until after the risk for self-harm is determined.

A nurse is reviewing the medication list of a client who presents with slow, involuntary muscle spasms of the arms and legs and twisting of the neck. The nurse reviews the client's prescriptions for which medication that could correlate with these symptoms? diazepam amitriptyline hydrochloride haloperidol clonazepam

haloperidol Haloperidol is a phenothiazine and is capable of causing dystonic reactions. Dystonia involves slow, involuntary contractions of an isolated muscle or groups of muscles in the limbs, trunk, and neck. It may involve spasmodic torticollis (involuntary turning of the neck). Diazepam and clonazepam are benzodiazepines. Benzodiazepines don't cause dystonic reactions; however, they can cause drowsiness, lethargy, and hypotension. Tricyclic antidepressants, like amitriptyline, rarely cause severe dystonic reactions; however, they can cause a decreased level of consciousness, tachycardia, dry mouth, and dilated pupils.

A client who has been hospitalized with schizophrenia for 8 years can't perform activities of daily living (ADLs) without staff direction and assistance. The nurse formulates a nursing diagnosis of dressing or grooming self-care deficit related to inability to function without assistance. What is an appropriate goal for this client? "Client will be able to complete ADLs with assistance in organizing grooming items and clothing within 1 month." "Client will be able to complete ADLs independently within 1 month." "Client will be able to complete ADLs with complete assistance within 1 month." "Client will be able to complete ADLs with only verbal encouragement within 1 month."

"Client will be able to complete ADLs with assistance in organizing grooming items and clothing within 1 month." The disorganized personality and history of hospitalization have affected this client's ability to perform self-care activities. Interventions should be directed at helping the client complete ADLs with the assistance of staff members, who can provide needed structure by helping the client select grooming items and clothing. This goal promotes realistic independence. As the client improves and achieves the established goal, the nurse may set new goals that focus on the client completing ADLs with only verbal encouragement and, ultimately, completing them independently. The client's condition doesn't indicate a need for complete assistance, which would only foster dependence.

The nurse is advising a client with schizophrenia about what to do when beginning to get agitated. The client has been compliant with taking medications and has worked with clinic staff on dealing with the illness and recognizing feelings of agitation. Indicate the order from first to last in which the nurse should suggest the actions be taken. All options must be used.

"Go to a quiet place." "Tell trusted people that you are becoming upset." "Take your oral lorazepam." "Take your oral haloperidol." Since external stimuli can greatly contribute to agitation, the nurse should teach the client that the first step is to go to a quiet area, then enlist the help of others, and finally take medication. Taking the lorazepam first would help decrease anxiety quickly, thus diminishing agitation. If the lorazepam is not successful, the client could take the oral haloperidol to help clear the client's thoughts and decrease agitation.

A nurse knows that a physician has ordered the liquid form of the drug chlorpromazine rather than the tablet form because the liquid: produces fewer anticholinergic effects. produces fewer drug interactions. has a longer duration of action. has a more predictable onset of action.

has a more predictable onset of action. A liquid phenothiazine preparation will produce effects in 2 to 4 hours. The onset with tablets is unpredictable.

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? "You know this is your medicine. They're the same pills you get every day. Please take them." "How would you feel if I allowed you to open the individual medication wrappers?" "Don't worry about what's in the pills. It's what the healthcare provider ordered." "Let's walk over to the water fountain and get a drink for you to take with your pills."

"How would you feel if I allowed you to open the individual medication wrappers?" Allowing a paranoid client to open the medication can help reduce suspicion. Telling the client "You know this is your medicine" is inappropriate and confrontational. Asking the client to accompany the nurse to the water fountain does not address the client's concern or suspicion. The best therapeutic answer addresses the client's concern, provides factual information, and is an open-ended question.

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? "You can be switched to another medicine." "Your weight gain will level off if you stay on the medication 3 more months." "I can help you with a diet and exercise plan to keep your weight down." "I don't think you look fat; why do you think so?"

"I can help you with a diet and exercise plan to keep your weight down." Helping the client control his weight is the most appropriate approach. The nurse's contradiction of the client's statement is inappropriate. Most atypical antipsychotics cause weight gain and are not a solution to the weight gain. There is little evidence that weight gain from taking olanzapine decreases with time.

After several months of taking olanzapine, the client reports that he is no longer hearing voices of any kind. Which statement would confirm that the client is developing insight into his illness? "That olanzapine is the best medicine I have ever had." "I didn't realize how sick I could get from a chemical brain imbalance." "I think I may be able to get a little part-time job soon." "My mom is proud of me for staying on my medicines."

"I didn't realize how sick I could get from a chemical brain imbalance." Insight into the illness is demonstrated when the client recognizes the relationship between the chemical imbalance and his illness and symptoms. Stating that the olanzapine is the best medicine or that the client's mother is proud of him for staying on his medicines reflects awareness about the effect of medications and the need for compliance. Stating that he may be able to get a part-time job indicates an awareness of his increased capacity for work.

A client who is experiencing hallucinations asks if a nurse hears the voices saying that the client should never have been born. The nurse's most appropriate response would be: "The voices are coming from inside you. They aren't real." "I don't hear any voices, but I believe you can hear them." "The voices are a symptom of your illness and will go away." "Sometimes I hear voices. What are your voices saying?"

"I don't hear any voices, but I believe you can hear them." The nurse admitting to not hearing the voices but believing that the client can hear them is an honest, straightforward response that acknowledges the truth without negating the reality of the client's experience. The voices may be a symptom of the client's illness, but stating that negates the client's feelings and sense of reality. Although asking what the voices are saying provides an opportunity for the client to talk further, a nurse who makes this statement identifies too much with the client's hallucinations and gives them undue credibility. Stating that the voices aren't real discounts the client's experience of reality.

A client with schizophrenia states, "I hear the voice of King Tut." Which response by the nurse is therapeutic? "You shouldn't focus on that voice; it is not real." "Does the voice sound like someone you know?" "King Tut has been dead for years, so that can't be his voice." "I don't hear the voice, but I know you hear what sounds like a voice."

"I don't hear the voice, but I know you hear what sounds like a voice." This response makes a factual statement about the client's hallucination. Telling the client not to focus on the voice is judgmental. Telling the client not to worry because the voice is not real is a flippant, dismissive response. Saying "King Tut has been dead for years" is dismissive.

One of the clients in group with a dual diagnosis of chronic schizophrenia and alcohol abuse states, "I am not going to take medicine every day." Which response by the nurse would be most appropriate? "I hear you say that you don't like taking medication daily." "Let's discuss this tomorrow if we have time." "Would anyone in group like to discuss this?" "Your health care provider wants you to take your medication everyday."

"I hear you say that you don't like taking medication daily." By saying, "I hear you say that you don't like taking medication daily," the nurse accepts the client's statement so that the client feels heard and understood. The nurse demonstrates openness toward hearing unacceptable attitudes to foster further sharing among the clients. The other statements are not helpful or therapeutic. The client is ignored and dismissed, which can lead to increased anxiety, decreased self-esteem, and increased anger toward the nurse and other clients.

A client with schizophrenia is responding well to risperidone and is no longer psychotic. After the nurse teaches the client about managing the illness, which statement by the client reflects a need for further intervention? "I just don't know if I can remember to keep taking medicines every day." "I can name the side effects of risperidone, but I'm not having any." "When my thoughts start racing, I know I need to relax more." "I don't listen to my mom's religious beliefs about not using medicines."

"I just don't know if I can remember to keep taking medicines every day." The major cause of relapse is nonadherence to the medication treatment plan. If the client is worried about remembering to take the medicines on a regular basis, it is a warning sign to the nurse that the client may be at risk for noncompliance. The nurse needs to discuss strategies to help the client establish a new routine such as using digital reminders, integrating medications into a daily routine, and utilizing family support systems when available. Understanding when to relax and the side effects of medicines are positive findings. Choosing not to listen to a family member's negative beliefs about medication is also a positive finding.

The client tells the nurse that she stopped taking olanzapine 2 weeks ago because she is better and wants "to make it on my own without this darned medicine." What would be the nurse's most therapeutic response? "You're a smart girl. You know what will happen if you don't take your medication. Why do you want to stop?" "Maybe you're ready for a short holiday from the olanzapine. I'll talk it over with the health care provider. But you need to keep taking it until I talk with your health care provider." "You've told me about other times like this when you stopped taking your medication and you got sick again. You should know better by now." "I know you get tired of taking the medication, especially when you are doing well. Is there any special reason you decided to stop right now?"

"I know you get tired of taking the medication, especially when you are doing well. Is there any special reason you decided to stop right now?" Recognizing the client's feelings and her progress while obtaining more information is the most therapeutic response. Reminding the client of her previous related experience is also appropriate but should not be done in a way that belittles and embarrasses the client. Challenging the client and asking questions designed to make her feel guilty are not therapeutic and are not likely to improve medication compliance. To suggest the possibility of a drug holiday when symptoms are recurring is clinically unsound.

The nurse should judge client education regarding valproic acid as effective if the client states which statement? "Valproic acid is safe to use when I get pregnant." "I might need to take the valproic acid for a long time." "I can take the valproic acid when I feel I need it." "I can stop the valproic acid because the serum level is normal."

"I might need to take the valproic acid for a long time." Because bipolar disorder is a biochemical disorder, the client needs to know that she may need medication for a length of time.Stopping the valproic acid may cause a return of symptoms.Valproic acid is never prescribed on an as-needed basis. Careful regular dosing is needed to prevent toxicity, manage symptoms, and balance brain neurotransmitters.Valproic acid is not safe to take during pregnancy because of the risk to the fetus. The client should inform the nurse and healthcare provider if she thinks she might be pregnant.

The parent of a young adult client diagnosed with schizophrenia is asking questions about his son's antipsychotic medication, ziprasidone. Which statement by the parent reflects a need for further teaching? "If he becomes dizzy, I'll make sure he doesn't drive." "If he experiences restlessness or muscle stiffness, he should tell his health care provider." "I should give him benztropine to help prevent constipation from the ziprasidone." "The ziprasidone should help him be more motivated and less withdrawn."

"I should give him benztropine to help prevent constipation from the ziprasidone." Constipation caused by medication is best managed by diet, fluids, and exercise. Benztropine can increase constipation. However, it may be prescribed for restlessness and stiffness. Restlessness and stiffness should be reported to the health care provider (HCP). Drowsiness and dizziness are adverse effects of ziprasidone. Clients should not drive if they are experiencing dizziness. Ziprasidone does help improve the negative symptoms of schizophrenia such as avolition.

A client reports having thoughts of being followed by foreign agents who are after his secret papers. Which response by the nurse is most appropriate when responding to the client's disturbed thought process? "I don't know what you mean." "I don't see any foreign agents." "I think these thoughts are frightening to you." "I would like you to come to group with me right now."

"I think these thoughts are frightening to you." The client's disturbed thought process likely reflects this client's paranoid delusions. The nurse should acknowledge that the thoughts are frightening the client. Telling the client the nurse does not see any foreign agents is an appropriate nursing response if the client is having disturbed visual sensory perception and is having visual hallucinations. Telling the client the nurse does not understand what the client means is an appropriate response if the client has impaired verbal communication. Suggesting that a client participate in group activities would be appropriate if the client had a nursing diagnosis of social isolation and was staying in his room.

A nurse is providing education to a client recently diagnosed with schizoaffective disorder. Further teaching is necessary when the client makes which statement? "Now that I am taking medications to help with my schizoaffective disorder, I can try to get my old job back." "It is important for me to call my health care provider if I start hearing voices telling me to hurt myself." "Because I have schizophrenia and a mood disorder, there may be times when I feel sad and times when I am extremely active." "I will need to get my blood drawn daily to check the levels of the antipsychotic medications."

"I will need to get my blood drawn daily to check the levels of the antipsychotic medications." According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, schizoaffective disorder refers to schizophrenia with elements of a mood disorder, either mania or depression. It is important for any client to call the health care provider when experiencing the urge to commit self-harm. If the client is able to function independently, the nurse should promote social skills and appropriate interactions with others, such as obtaining an old job. Daily blood draws are unnecessary for antipsychotic medications.

While pacing in the hall, a client with schizophrenia runs to a nurse and asks, "Why are you poisoning me? I know you work for Central Thought Control! You can keep my thoughts. Give me back my soul!" How should the nurse respond during the early stage of the therapeutic process? "I'm a nurse, and you're a client in the hospital. I'm not going to harm you." "I sense anger. Are you feeling angry today?" "I'm a nurse. I'm not poisoning you. That would be a violation of the nursing code of ethics." "I'm not poisoning you. And how could I possibly steal your soul?"

"I'm a nurse, and you're a client in the hospital. I'm not going to harm you." The nurse should directly orient a delusional client to reality, especially to place and person. Denying poisoning and offering delusion-related information may encourage further delusions related to the delusion. Validating the client's feelings occurs during a later stage in the therapeutic process.

The nurse is caring for a client taking risperidone 2 mg daily. It is most important for the nurse to follow up on which client statement? "I take my medication every morning before breakfast." "I'm constantly sick and feel like I always have a fever." "Sometimes I get dizzy if I stand up quickly." "I've been exercising regularly and lost 5 pounds."

"I'm constantly sick and feel like I always have a fever." A major adverse reaction of risperidone is agranulocytosis. Therefore, it is a priority for the nurse to follow up if the client reports constantly being sick. Risperidone can be given without regard to meals; taking it at the same time every day is encouraged. Clients are encouraged to exercise regularly; the nurse should monitor the client taking risperidone for weight gain. Orthostatic hypotension is a common side effect of risperidone, and the nurse should follow up; however, the priority concern is agranulocytosis. Additionally, the client indicates experiencing dizziness "sometimes" but the feeling sick "constantly."

The nurse has given a client with schizophrenia discharge instructions. Which statement by the client would indicate understanding of the teaching? Select all that apply. "Anxiety makes it more likely I will hear voices." "I can skip a pill when I am feeling too tired from them." "If I am having trouble sleeping or eating, I will call the mental health center." "I can't drink even one or two beers." "Possible bad effects from the pills only last a few days."

"If I am having trouble sleeping or eating, I will call the mental health center." "I can't drink even one or two beers." "Anxiety makes it more likely I will hear voices." In schizophrenia, the client and the family need to receive teaching in order to manage the illness and to prevent a relapse. In the initial phase of the illness, teaching will need to be continued at the health care provider's office or the local mental health center. The client needs to understand that difficulty with eating or sleeping or increased anxiety can increase symptoms. Alcohol even in small amounts depresses the CNS and can interfere with pharmacological actions of medications. Reactions to the client's medications like tardive dyskinesia, dystonia, or the other extra-pyramidal side effects may take longer periods of time. The client needs to report any unusual symptoms.

The nurse is providing discharge teaching to a client diagnosed with schizophrenia. Which client statement(s) would cause the nurse to intervene? Select all that apply. "I'll call if I develop muscle twitches I can't control." "I'll exercise 3 times a week and stop eating fast food." "I should look for a mental health support group." "As soon as I start feeling like myself again, I'll decrease my medications." "If the voices come back, I'll stay at home to ensure my safety."

"If the voices come back, I'll stay at home to ensure my safety." "As soon as I start feeling like myself again, I'll decrease my medications." Clients diagnosed with schizophrenia should not stop or decrease their medications without the direction of a health care provider. Many antipsychotic medications require a constant dose to be effective. If a client diagnosed with schizophrenia begins to hear voices again, the client should call the healthcare provider to be seen. If the client indicates a lack of understanding of these ideas, the nurse needs to do further teaching. A support group could be helpful, and exercising regularly and eating healthy are important. The client should contact the health care provider if involuntary muscle contractions occur, as this is a sign of dystonia, a side effect of antipsychotic medications.

A client with antisocial personality disorder tells the nurse, "I punched the guy out because he deserved it, and then the cops arrested me." Which response would be most helpful to the client? "I wouldn't do that again if I were you." "If you punch people out, you'll get into trouble." "Don't ever do that again; you're an adult." "It's wrong to punch others."

"If you punch people out, you'll get into trouble." Saying "If you punch people out, you'll get into trouble" helps the client by pointing out the negative consequences of his behavior. Clients with antisocial personality disorder are aggressive, impulsive, and reckless; engage in illegal activities; and lack guilt or remorse. The nurse teaches the client that there are consequences to his irresponsible behavior and that the way to stay out of trouble is to change his behavior. Saying, "It's wrong to punch others," is not helpful since the client does not feel guilt or remorse. Saying, "I wouldn't do that again if I were you" or "Don't ever do that again," is authoritative and scolds the client without helping him.

A client perceives that her roommate's stuffed animal is her own dog at home. The nurse determines that this misperception of reality (illusion) is improving when the client makes which statement? "I guess Jan needs a dog as much as I do." "Jan's dog and my dog could be twins." "I wish Jan had not had my dog stuffed." "Jan's stuffed dog looks somewhat like my dog."

"Jan's stuffed dog looks somewhat like my dog." Recognition by the client that there is a difference between the stuffed animal and her live dog indicates that the client perceives the reality of the situation. Stating that the stuffed animal and the client's dog could be twins reflects the client's continued misperception of reality, thinking that the stuffed animal and her dog are one and the same. Stating that she wishes her dog had not been stuffed reflects her continued misperception of reality. Stating that the roommate needs a dog as much as she does is unrelated to the client's perception or misperception of reality.

The nurse is admitting a client to the psychiatric unit. Suddenly, the client states, "They're all plotting to destroy me. Isn't that true?" Which would be the most appropriate response? "What reason would people have to want to destroy you?" "People here are trying to help you if you will let them." "That doesn't make any sense; nurses are helpers, not murderers." "Please explain that to me."

"Please explain that to me." Clients with fixed false beliefs truly believe the content of the delusion. Arguing or explaining will not help as in the other options. Initially the nurse needs to know the content and depth of the delusion while the client is being admitted. Then the nurse needs to focus on how the client feels about the delusion or distract the client from the delusion during the conversation.

A client diagnosed with schizophrenia is being switched to risperidone long-acting injection. The client is told that he will remain on his oral dose of risperidone daily for approximately 1 month. The client says, "I didn't have to take pills when I was on fluphenazine shots in the past." What should the nurse tell the client? "Risperidone long-acting injection is less potent than fluphenazine." "Your health care provider did not believe you would take both the pills and fluphenazine injections." "Taking fluphenazine orally and by injection would not be as effective as the injection alone." "Risperidone long-acting injection initially takes a little longer to reach the ideal blood level."

"Risperidone long-acting injection initially takes a little longer to reach the ideal blood level." Achieving a therapeutic blood level is a slower process with risperidone long-acting injection. Oral fluphenazine does not decrease the effectiveness of the intramuscular version and might increase the incidence of adverse effects. There is no evidence that the potency of the two medications is significantly different. Blaming the client for noncompliance with these two medications is inappropriate.

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? "Others can hear you." "You know better than to use that language." "You need to act like an adult." "Stop! Swearing is not appropriate behavior."

"Stop! Swearing is not appropriate behavior." The nurse sets limits on unacceptable or threatening behavior to help the client regain control and preserve his self-esteem. Saying, "You need to act like an adult," is an authoritarian comment that shames the client and diminishes self-esteem. Saying, "You know better than that," shames the client and diminishes self-worth. Saying, "Others can hear you," is not helpful because it does not identify the unacceptable behavior.

The parents of a 20-year-old female client diagnosed with paranoid schizophrenia admitted 4 days ago are attending a family psychoeducation group in the hospital. Which statement by the mother indicates that she understands her daughter's illness and management? "She won't experience a relapse as long as she takes her prescribed medication." "I know that I'll have to do everything for my daughter when she comes home." "Tasks as simple as getting out of bed and showering in the morning may be difficult for her." "I know that visits from her friends at home should be discouraged for a while."

"Tasks as simple as getting out of bed and showering in the morning may be difficult for her." Clients with paranoid schizophrenia experience alterations in thought resulting in introspection, confusion, and distraction from external reality. Simple tasks that require concentration and effort, including activities involving self-care, may be difficult for the client, especially during the acute phase of the illness. However, the mother should not need to do everything for her daughter. Rather, the mother should encourage the daughter to do things for herself with guidance. Visits from friends should be discussed with the client, and the client should be encouraged to visit with friends to minimize the risk of social isolation. Although relapse typically occurs with medication noncompliance, vulnerability to stress, a low threshold for stress, the number of stresses, and the client's lack of adaptive coping behaviors contribute to relapse.

A client with a 5-year history of multiple psychiatric admissions is brought to the emergency department by the police. This client was found wandering the streets disheveled, shoeless, and confused. The client points to the police officer and states, "That person was sent by the devil to kill me." Which response by the nurse is best? "I have taken care of lots of clients who felt the same way. The feeling will pass." "Try to ignore the police officer. Come sit down, and we can get you something to eat." "That sounds scary. That person is a police officer and brought you to the hospital." "No. That is untrue. That person is a police officer and is here to help you."

"That sounds scary. That person is a police officer and brought you to the hospital." This client is experiencing a psychotic break as evidenced by the delusion and disorganized behavior. The nurse should address the client's feelings and provide factual information. Stating the client's thinking is "untrue" is confrontational. Asking the client to ignore the police officer dismisses the client's feelings. Telling the client the nurse has taken care of others in the same situation focuses on the nurse and other clients. The most therapeutic response should address the client's feelings and provide correct information.

A client with chronic schizophrenia is admitted to the hospital on an emergency detention. The client states to the nurse, "I didn't do anything wrong. I was just carrying out the orders God gave me to paint an X on the door of all sinners." Several hours after being admitted, the client wants to leave the hospital. In addition to explaining that the staff is concerned about the client's health and safety, which of the following should the nurse tell the client? "The law requires you to stay here until you are well." "The court has mandated that you undergo a 72-hour evaluation." "You must stay at least 2 days but then may be able to leave." "It will take about 24 hours to complete the evaluation."

"The court has mandated that you undergo a 72-hour evaluation." Clients admitted on an emergency detention must remain hospitalized for the time allotted for the evaluation. In this case, the time is 72 hours. The 72 hours do not include weekends or holidays. If the treatment team completes the evaluation in less than the allotted time, they may decide to discharge the client or may institute further commitment procedures. Clients cannot sign themselves out of the hospital during this period. Family members also cannot authorize the client's release. A client on an emergency detention can be held involuntarily for 72 hours. An immediate detention is good for only 24 hours. Telling the client that the stay must be 2 days is less than the time mandated by the court. The emergency detention in this case allots 72 hours for the evaluation. Once this time frame has passed and the primary care provider has not initiated or filed papers for commitment, the client may sign himself out of the institution, be discharged by the primary care provider, or sign papers as a voluntary admission.

A client with schizophrenia was brought to the hospital after being hit by a car. Assessment reveals no serious injuries. The client states, "All these machines are reading my thoughts! Turn them off!" Which response by the nurse is best? "Have you been taking your medications? Have you been having many delusions?" "The machines can't harm you, so you're safe. I use them to check your blood pressure." "I understand you're worried. How long have machines been reading your thoughts?" "Please don't worry. I'm using these machines to help us take good care of you."

"The machines can't harm you, so you're safe. I use them to check your blood pressure." The client is experiencing delusions, which are false sensory perceptions. The best therapeutic response by the nurse addresses the client's safety and provides factual information. Nurses should not tell the client not to worry or explore the delusion. Asking whether the client took the medications is a yes/no question and is focused on the past, not on the here and now. Additionally, this response does not address the safety concern of the client.

A client with a paranoid personality disorder sees some clients laughing during a group activity and asks the nurse, "Why are they laughing at me? I bet they're making fun of me." Which response by the nurse is most appropriate? "Look. They seem to be having fun." "They're laughing at a joke John told. They're not laughing at you." "Don't worry about them. They don't mean any harm." "You shouldn't let yourself get so upset."

"They're laughing at a joke John told. They're not laughing at you." The client with paranoid personality disorder interprets the actions of others as personal threats, feels vulnerable, and is overly sensitive to others' motives. Saying "They're laughing at a joke John told. They're not laughing at you" is a simple explanation of others' behavior, which helps to decrease the client's suspiciousness and promote trust. The other statements do not help the client to realistically interpret situations and the behavior of others and are not helpful in reducing the client's suspicions or mistrust.

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? "With whom do you want to do things?" "How much money can you spend?" "What kind of transportation do you use?" "What activities did you enjoy in the past?"

"What activities did you enjoy in the past?" Knowing the client's interests is the best place to begin to help the client resocialize. Knowing with whom the client wishes to socialize, what transportation she has, or how much spending money she has may be relevant questions, but these questions should be asked after the question concerning what activities the client enjoyed in the past.

A client is sitting in the corner of the dayroom cocking his head to one side as if he hears something, but no one is nearby. The nurse suspects he is having auditory hallucinations. Which question should the nurse ask first? "What are you hearing right now?" "Are you seeing someone other than me?" "Do you want to go to the recreation room?" "What is going on with you right now?"

"What are you hearing right now?" Before intervening with the client experiencing hallucinations, the nurse must validate what the client is experiencing. Asking the client what he hears right now accomplishes this. Asking about seeing someone near the client would be appropriate to validate visual hallucinations. Asking the client about what is going on may be helpful. However, the question is too general to validate that the client is experiencing auditory hallucinations. Asking the client if he wants to go to the recreation room might be appropriate after the nurse has validated what the client is experiencing.

A client admitted in an acute psychotic state hears terrible voices in the head and thinks a neighbor is upset with the client. What is the nurse's best response? "What exactly are these terrible voices saying to you?" "We won't let your neighbor visit, so you'll be safe." "What has your neighbor been doing that bothers you?" "How long have you been hearing these terrible voices?"

"What exactly are these terrible voices saying to you?" The nurse needs to collect additional information about the client's report about hearing voices. Assessing the content of hallucinations is essential to determine whether they are command hallucinations that the client might act on. Asking about what the neighbor has been doing or telling the client that the neighbor will not visit indirectly reinforces the delusion about the neighbor. Although determining the onset and duration of the voices is important, the nurse needs to assess the content of the hallucinations first.

A 20-year-old client with paranoid schizophrenia is in the 4th day of hospitalization. The client's parents visit and state to the nurse, "What did we do wrong? What caused this awful thing to happen?" Which explanation by the nurse is most accurate and therapeutic? "Schizophrenia often appears for the first time in early adulthood when people with a predisposition experiment with drugs and alcohol." "You did not cause schizophrenia by doing something wrong. Schizophrenia is a brain disease." "Let's talk about your family background. Schizophrenia is often genetic." "We really do not know. There are many theories about schizophrenia."

"You did not cause schizophrenia by doing something wrong. Schizophrenia is a brain disease." The nurse is sensitive to the parents' feeling of guilt and lack of knowledge about the etiologies of schizophrenia. The nurse reassures the parents that they are not to blame for their child's illness. The nurse then begins to educate them by explaining the biological theories of the disease in a simple, straightforward manner.Telling the parents that the cause of schizophrenia is unknown ignores the their concerns and diminishes trust in the nurse by not offering accurate information about the disorder.Stating that schizophrenia is genetic implies that the parents are to blame and offers an incomplete explanation of the disorder.Telling the parents schizophrenia is related to drug and alcohol use makes an inappropriate suggestion that the client's behavior caused the disease.

Which concept is most important for a nurse to communicate to a client preparing to sign an informed consent for electroconvulsive therapy (ECT)? "This therapy will provide excellent symptom relief." "You may experience a complete loss of memory after the treatment." "You may experience a time of confusion after the treatment." "You'll be offered a strong sedative before the procedure."

"You may experience a time of confusion after the treatment." The nurse should explain that the client may experience a time of confusion following ECT as a result of electricity passing through the cerebral cortex and disrupting nerve impulses. Although it's true that the client will be offered a sedative, communicating this information isn't an essential component of informed consent. It's unrealistic to promise a client that the procedure will provide symptom relief. Complete memory loss isn't an expected response to ECT.

A client with schizophrenia repeatedly uses profanity during an activity therapy session. Which response by the nurse is appropriate? "You're just doing this to get back at me for making you come to therapy." "I'm disappointed in you. You can't control yourself for even a few minutes." "Your cursing is interrupting the activity. Take time out in your room for 10 minutes." "Your behavior won't be tolerated. Go to your room immediately."

"Your cursing is interrupting the activity. Take time out in your room for 10 minutes." The nurse should set limits on client behavior to ensure a comfortable environment for all clients. The nurse should accept hostile or quarrelsome client outbursts within limits without becoming personally offended. Stating that the client's behavior is a way of punishing the nurse is incorrect because it implies that the client's actions reflect feelings toward the staff instead of the client's own misery. Judgmental remarks, such as "I'm disappointed in you" and "You can't control yourself" may decrease the client's self-esteem.

A client diagnosed with schizophrenia gained 50 lb (22.7 kg) in 6 months while taking olanzapine. After a prescription change from olanzapine to ziprasidone, the client tells the nurse, "I don't want to take this ziprasidone either. I can't gain any more weight." Which response by the nurse is most appropriate for this client? "We can give it to you as an injection rather than in capsule form." "Abnormal movements are not as common with ziprasidone." "You can take it just before bedtime, so you won't need a snack." "Ziprasidone causes less weight gain than the other atypical antipsychotics."

"Ziprasidone causes less weight gain than the other atypical antipsychotics." Most clients experience less weight gain when taking ziprasidone. Although ziprasidone can be administered intramuscularly, it can be used only on an as needed basis by this route. Ziprasidone has fewer extrapyramidal side effects, but that is not this client's major concern. Ziprasidone is better absorbed when taken with food, so a bedtime snack is needed.

During group therapy, a client constantly interrupts with impulsive behavior and exaggerated stories that cast the client as a hero. The client also manipulates the group with attention-seeking behaviors, such as sexual comments and angry outbursts. The nurse assesses that these behaviors are best correlated with which diagnosis? avoidant personality disorder histrionic personality disorder borderline personality disorder paranoid personality disorder

histrionic personality disorder This client's behaviors are typical of histrionic personality disorder, which is marked by emotional lability and attention seeking. The client constantly seeks and demands attention, approval, or praise; may be seductive in behavior, appearance, or conversation; and is uncomfortable except when the center of attention. Clients with paranoid personality disorder are typically suspicious, cold, hostile, and argumentative. Avoidant personality disorder is characterized by anxiety, fear, and social isolation. Borderline personality disorder is characterized by impulsive, unpredictable behavior and unstable, intense interpersonal relationships.

A client tells the nurse, "Everybody smiles at me because they know that I was chosen by God for this mission." The nurse interprets this statement as which finding? neologism thought insertion idea of reference visual hallucination

idea of reference An idea of reference is a person's view that other people recognize that she has an important characteristic or power. Thought insertion refers to a person's belief that others, or a specific other, can put thoughts into her mind. Visual hallucinations involve seeing objects or persons not based on reality. A neologism is a word or phrase that has meaning only to the person using it.

A client tells a nurse that the television newscaster is sending the client a secret message. The nurse suspects the client is experiencing: a delusion. flight of ideas. ideas of reference. a hallucination.

ideas of reference. Ideas of reference refers to the mistaken belief that neutral stimuli have special meaning to an individual, such as the television newscaster sending a message directly to the client. A delusion is a false belief. Flight of ideas is a speech pattern in which the client skips from one unrelated subject to another. A hallucination is a sensory perception, such as hearing voices and seeing objects, that only the client experiences.

Which intervention is essential when caring for a client who is experiencing delirium? identifying the underlying causative condition or illness decreasing or discontinuing all previously prescribed medications manipulating the environment to increase orientation controlling behavioral symptoms with low-dose psychotropics

identifying the underlying causative condition or illness The most critical aspect of caring for the client with delirium is to institute measures to correct the underlying causative condition or illness. Controlling behavioral symptoms with low-dose psychotropics, manipulating the environment, and decreasing or discontinuing all medications may be dangerous to the client's health.

A client diagnosed with borderline personality disorder has self-inflicted cuts on the arms. The nurse is assessing the client for the risk of suicide. What should the nurse ask the client first? if the client is taking antidepressants if the client has a suicide plan why the client self-inflicted the cuts about medications the client has taken recently

if the client has a suicide plan The client is at risk for suicide, and the nurse should determine how serious the client is, including if the client has a plan and the means to implement the plan. While medication history may be important, the nurse should first attempt to determine suicide risk. Asking why the client made the self-inflicted cuts will likely cause the client to respond with insufficient information to determine suicide risk.

A client with schizoaffective disorder is brought to the hospital by a family member. The family member states that the client is having an increase in auditory hallucinations and is becoming significantly more withdrawn. The nurse reviewing the admission blood work expects which blood level to be subtherapeutic? chlordiazepoxide phenobarbital imipramine lithium carbonate

lithium carbonate Lithium carbonate, an antimanic drug, is used to treat clients with cyclical schizoaffective disorder, a psychotic disorder once classified under schizophrenia that causes affective symptoms, including manic and depressive activity. Lithium helps control this disorder's affective component. Phenobarbital can cause schizophrenia-like symptoms in some people and would not be prescribed for a person with schizophrenia. Chlordiazepoxide, an antianxiety agent, is generally contraindicated in psychotic clients. Imipramine, primarily considered an antidepressant agent, is also used to treat clients with agoraphobia and those undergoing cocaine detoxification.

Which group of characteristics should a nurse expect to see in the client with schizophrenia? periods of hyperactivity and irritability alternating with depression sadness, apathy, feelings of worthlessness, anorexia, and weight loss loose associations, grandiose delusions, and auditory hallucinations delusions of jealousy and persecution, paranoia, and mistrust

loose associations, grandiose delusions, and auditory hallucinations Loose associations, grandiose delusions, and auditory hallucinations are all characteristic of the classic schizophrenic client. These clients aren't able to care for their physical appearance. They frequently hear voices telling them to do something either to themselves or to others. Additionally, they ramble verbally from one topic to the next. Periods of hyperactivity and irritability alternating with depression are characteristic of bipolar disorder. Delusions of jealousy and persecution, paranoia, and mistrust are characteristics of paranoid disorders. Sadness, apathy, feelings of worthlessness, anorexia, and weight loss are characteristics of depression.

A nurse is assessing a new client and notices clang associations in the speech pattern. From this assessment finding, the nurse begins to evaluate for the potential of which psychiatric conditions? Select all that apply. mania cognitive disorders intermittent explosive disorder schizophrenia narcolepsy dissociative identity disorder

mania cognitive disorders schizophrenia This speech pattern, characterized by meaningless rhymes, is found most commonly in clients with schizophrenia but may also be present in those with bipolar disorder (during the manic phase) and cognitive disorders. In some cases, clang associations can be linked to the inability to communicate. It is not characteristic of dissociative identity disorders, narcolepsy, or explosive disorders.

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? controlling matter-of-fact authoritarian parental

matter-of-fact For this client, the nurse needs to use a calm, matter-of-fact approach to create a nonthreatening and secure environment because the client is experiencing problems with suspiciousness and trust. Use of "I" statements and responses would be therapeutic to reduce the client's suspiciousness and increase his trust in the staff and the environment. An authoritarian approach is nontherapeutic and inappropriate because the client may perceive this approach as an attack, subsequently responding with anger and threatening behavior. A parental or controlling approach may be perceived as authoritarian, and the client may become defensive and angry.

A nurse is assigned to a client with catatonic schizophrenia. Which intervention should the nurse include in this client's care plan? providing a quiet environment in which the client can be alone giving the client an opportunity to express concerns meeting all of the client's physical needs administering lithium carbonate as ordered

meeting all of the client's physical needs Because a client with catatonic schizophrenia can't meet physical needs independently, the nurse must provide for all of these needs, including adequate food and fluid intake, exercise, and elimination. Although this client is incapable of expressing concerns, the nurse should try to verbalize the message the nonverbal behavior conveys. Lithium is used to treat mania, not catatonic schizophrenia. Despite the client's mute, unresponsive state, the nurse should provide nonthreatening stimulation and should spend time with the client, not leave the client alone all the time. Although aware of the environment, the client doesn't actively interact with it; the nurse's support and presence can be reassuring.

A client with schizophrenia displays a lack of interest in activities, reduced affect, and poor ability to perform activities of daily living. What term would be used to describe this clustering of symptoms? positive symptoms negative symptoms extrapyramidal symptoms physiologic symptoms

negative symptoms Schizophrenic clients commonly display positive and negative symptoms. Negative symptoms are characterized by the absence of typically displayed emotional responses. Clients with these symptoms tend to respond poorly to medication. Positive symptoms, such as auditory or visual hallucinations, are characterized by enhancement of a sensory modality. These aren't physiologic symptoms of schizophrenia. Extrapyramidal symptoms may result from long-term antipsychotic drug use in schizophrenics.

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? tardive dyskinesia dystonia akathisia neuroleptic malignant syndrome

neuroleptic malignant syndrome The client's signs and symptoms suggest neuroleptic malignant syndrome, a life-threatening reaction to neuroleptic medication that requires immediate treatment. Tardive dyskinesia causes involuntary movements of the tongue; mouth; and muscles of the face, arms, and legs. Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles. Akathisia causes restlessness, anxiety, and jitteriness.

What is the priority symptom to assess for in the client who is taking risperidone 1 mg, orally twice a day? headache anxiety orthostatic hypotension insomnia

orthostatic hypotension Significant orthostatic hypotension is associated with risperidone therapy. The nurse should monitor the client's blood pressure sitting and standing and teach the client interventions to manage this adverse effect to prevent risk of injury. Although insomnia, headache, and anxiety are possible adverse effects of risperidone therapy, they are of less immediate concern than orthostatic hypotension.

A client is admitted with a diagnosis of schizotypal personality disorder. Which signs would this client exhibit during social situations? independence needs paranoid thoughts emotional affect aggressive behavior

paranoid thoughts Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts. Aggressive behavior is uncommon, although these clients may experience agitation with anxiety. Their behavior is emotionally cold with a flattened affect, regardless of the situation. These clients demonstrate a reduced capacity for close or dependent relationships.

A client's nursing care plan includes the following prescription: "Assess for auditory hallucinations." What behavior would suggest to the nurse the client may be experiencing auditory hallucinations? distrust, fear, suspicion performing rituals, avoiding open places poor eye contact, tilted head, mumbling to self elevated mood, hyperactivity, distractibility

poor eye contact, tilted head, mumbling to self Cues that the client is experiencing auditory hallucinations include eyes looking around the room as though looking for a speaker, tilting the head to one side as though listening, and mumbling or talking aloud as though responding to someone. Performing rituals and avoiding open places is associated with anxiety and compulsive behaviors. Elevated mood and hyperactivity are features of a manic episode. Distrust and suspicion are prevalent in paranoia.

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? communication problems potential for medication noncompliance disturbed thought process disturbed sensory perceptions

potential for medication noncompliance Though disturbed thoughts and sensory perceptions would be a concern to the nurse, as would communication issues, the primary issue for this client in terms of his comments would be the potential for medication noncompliance and relapse. Most college students want to be like their peers and perceive themselves as capable and well. These beliefs can lead a young client with schizophrenia to stop taking medication, which leads to relapse.

A client with schizophrenia has been experiencing auditory hallucinations for many years. One approach that has proven to be effective is for hallucinating clients to: practice saying, "Go away" or "Stop" when they hear voices. take an as-needed dose of psychotropic medication whenever they hear voices. sing loudly to drown out the voices and provide a distraction for themselves. go to their room until they can't hear the voices.

practice saying, "Go away" or "Stop" when they hear voices. Researchers have found that some clients can learn to control bothersome hallucinations by telling the voices to go away or stop. Taking an as-needed dose of psychotropic medication whenever the voices arise may lead to overmedication and put the client at risk for adverse effects. Because the voices aren't likely to go away permanently, the client must learn to deal with the hallucinations without relying on drugs. Although distraction is helpful, singing loudly may upset other clients and would be socially unacceptable after the client is discharged. Hallucinations are most bothersome in a quiet environment when the client is alone, so sending the client to another room would increase, rather than decrease, the hallucinations.