Psychotic Disorders - Schizophrenia, Personality Disorders from NCLEX 3000

A client tells the nurse that the television newscaster is sending a secret message to her. The nurse suspects the client is experiencing: 1. a delusion. 2. flight of ideas. 3. ideas of reference. 4. a hallucination.

A client tells the nurse that the television newscaster is sending a secret message to her. The nurse suspects the client is experiencing: 1. a delusion. 2. flight of ideas. 3. ideas of reference. 4. a hallucination. Correct Answer: 3 RATIONALES: Ideas of reference refers to the mistaken belief that neutral stimuli have special meaning to the individual such as the television newscaster sending a message directly to the individual. 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. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Knowledge

A physician starts a client on the antipsychotic medication haloperidol (Haldol). The nurse is aware that this medication has extrapyramidal adverse effects. Which nursing measures should the nurse take during haloperidol administration? Select all that apply: 1. Review subcutaneous injection technique. 2. Closely monitor vital signs, especially temperature. 3. Provide the client with the opportunity to pace. 4. Monitor blood glucose levels. 5. Provide the client with hard candy. 6. Monitor for signs and symptoms of urticaria.

A physician starts a client on the antipsychotic medication haloperidol (Haldol). The nurse is aware that this medication has extrapyramidal adverse effects. Which nursing measures should the nurse take during haloperidol administration? Select all that apply: 1. Review subcutaneous injection technique. 2. Closely monitor vital signs, especially temperature. 3. Provide the client with the opportunity to pace. 4. Monitor blood glucose levels. 5. Provide the client with hard candy. 6. Monitor for signs and symptoms of urticaria. Correct Answer: 2,3,5 RATIONALES: Neuroleptic malignant syndrome is a life-threatening extrapyramidal adverse effect of antipsychotic medications such as haloperidol. It's associated with a rapid increase in temperature. The most common extrapyramidal adverse effect, akathisia, is a form of psychomotor restlessness that can often be relieved by pacing. Haloperidol and the anticholinergic medications that are provided to alleviate its extrapyramidal effects can result in dry mouth. Providing the client with hard candy to suck on can help alleviate this problem. Haloperidol isn't given subcutaneously and doesn't affect blood glucose levels. Urticaria isn't usually associated with haloperidol administration. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological therapies COGNITIVE LEVEL: Analysis

A 24-year-old client is experiencing an acute schizophrenic episode. He has vivid hallucinations that are making him agitated. The nurse's best response at this time would be to: 1. take the client's vital signs. 2. explore the content of the hallucinations. 3. tell him his fear is unrealistic. 4. engage the client in reality-oriented activities.

A 24-year-old client is experiencing an acute schizophrenic episode. He has vivid hallucinations that are making him agitated. The nurse's best response at this time would be to: 1. take the client's vital signs. 2. explore the content of the hallucinations. 3. tell him his fear is unrealistic. 4. engage the client in reality-oriented activities. Correct Answer: 2 RATIONALES: Exploring the content of the hallucinations will help the nurse understand the client's perspective on the situation. The client shouldn't be touched, such as in taking vital signs, without telling him exactly what is going to happen. Debating with the client about his emotions isn't therapeutic. When the client is calm, engage him in reality-based activities. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Analysis

A 62-year-old male client with paranoid schizophrenia tells a nurse that he wants to die. After further discussion, the nurse discovers that the client doesn't have a suicide plan. Which response by the nurse is appropriate? 1. "I feel like that sometimes. Don't worry, you'll feel better soon." 2. "I would like to explore your thoughts further. Can you tell me more?" 3. "Excuse me while I discuss your thoughts with my nursing supervisor." 4. "When your medications reach therapeutic levels, you'll no longer have those feelings."

A 62-year-old male client with paranoid schizophrenia tells a nurse that he wants to die. After further discussion, the nurse discovers that the client doesn't have a suicide plan. Which response by the nurse is appropriate? 1. "I feel like that sometimes. Don't worry, you'll feel better soon." 2. "I would like to explore your thoughts further. Can you tell me more?" 3. "Excuse me while I discuss your thoughts with my nursing supervisor." 4. "When your medications reach therapeutic levels, you'll no longer have those feelings." Correct Answer: 2 RATIONALES: The nurse's use of active listening and therapeutic communication allows the client to explore his thoughts more fully. Telling the client not to worry offers false reassurance. The nurse should obtain more data from the client before reporting the incident to her nursing supervisor. Advising the client that medications will change his feelings could falsely reassure the client; he might not feel better after medications reach therapeutic levels. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Coordinated care COGNITIVE LEVEL: Analysis

A client is about to be discharged with a prescription for the antipsychotic agent haloperidol (Haldol), 10 mg by mouth twice per day. During a discharge teaching session, the nurse should provide which instruction to the client? 1. Take the medication 1 hour before a meal. 2. Decrease the dosage if signs of illness decrease. 3. Apply a sunscreen before exposure to the sun. 4. Increase the dosage up to 50 mg twice per day if signs of illness don't decrease.

A client is about to be discharged with a prescription for the antipsychotic agent haloperidol (Haldol), 10 mg by mouth twice per day. During a discharge teaching session, the nurse should provide which instruction to the client? 1. Take the medication 1 hour before a meal. 2. Decrease the dosage if signs of illness decrease. 3. Apply a sunscreen before exposure to the sun. 4. Increase the dosage up to 50 mg twice per day if signs of illness don't decrease. Correct Answer: 3 RATIONALES: 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. Finally, the nurse should instruct the client not to decrease or increase the dosage unless the physician orders it. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological therapies COGNITIVE LEVEL: Application

A client is unable to get out of bed and get dressed unless the nurse prompts every step. This is an example of which behavior? 1. Word salad 2. Tangential 3. Perseveration 4. Avolition

A client is unable to get out of bed and get dressed unless the nurse prompts every step. This is an example of which behavior? 1. Word salad 2. Tangential 3. Perseveration 4. Avolition Correct Answer: 4 RATIONALES: Avolition refers to impairment in the ability to initiate goal-directed activity, lack of motivation, and inattention to needs such as personal hygiene and activities of daily living. Word salad is when a group of words are put together in a random fashion without logical connection. Tangential behavior is exhibited when a person never gets to the point of the communication. Perseveration is when a person repeats the same word or idea in response to different questions. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Application

A client with borderline personality disorder becomes angry when he is told that today's psychotherapy session with the nurse will be delayed 30 minutes because of an emergency. When the session finally begins, the client expresses anger. Which response by the nurse would be helpful in dealing with the client's anger? 1. "If it had been your emergency, I would have made the other client wait." 2. "I know it's frustrating to wait. I'm sorry this happened." 3. "Can we talk about how this is making you feel right now?" 4. "I really care about you and I'll never let this happen again."

A client with borderline personality disorder becomes angry when he is told that today's psychotherapy session with the nurse will be delayed 30 minutes because of an emergency. When the session finally begins, the client expresses anger. Which response by the nurse would be helpful in dealing with the client's anger? 1. "If it had been your emergency, I would have made the other client wait." 2. "I know it's frustrating to wait. I'm sorry this happened." 3. "Can we talk about how this is making you feel right now?" 4. "I really care about you and I'll never let this happen again." Correct Answer: 3 RATIONALES: This response may diffuse the client's anger by helping to maintain a therapeutic relationship and addressing the client's feelings. Option 1 wouldn't address the client's anger. Option 2 is incorrect because the client with a borderline personality disorder blames others for things that happen, so apologizing reinforces the client's misconceptions. The nurse can't promise that a delay will never occur again, as in option 4, because such matters are outside the nurse's control. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Application

A client with paranoid schizophrenia has been experiencing auditory hallucinations for many years. One approach that has proven to be effective for a hallucinating client is to: 1. take an as-needed dose of psychotropic medication whenever he hears voices. 2. practice saying "Go away" or "Stop" when he hears voices. 3. sing loudly to drown out the voices and provide a distraction. 4. go to his room until the voices go away.

A client with paranoid schizophrenia has been experiencing auditory hallucinations for many years. One approach that has proven to be effective for a hallucinating client is to: 1. take an as-needed dose of psychotropic medication whenever he hears voices. 2. practice saying "Go away" or "Stop" when he hears voices. 3. sing loudly to drown out the voices and provide a distraction. 4. go to his room until the voices go away. Correct Answer: 2 RATIONALES: 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 his room would increase, rather than decrease, the hallucinations. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Knowledge

A client with schizophrenia hears a voice telling him he is evil and must die. The nurse understands that the client is experiencing: 1. a delusion. 2. flight of ideas. 3. ideas of reference. 4. a hallucination.

A client with schizophrenia hears a voice telling him he is evil and must die. The nurse understands that the client is experiencing: 1. a delusion. 2. flight of ideas. 3. ideas of reference. 4. a hallucination. Correct Answer: 4 RATIONALES: 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 the 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. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Knowledge

A client with schizophrenia is admitted to the facility. When collecting data about the client, the nurse should document which symptoms as negative symptoms of schizophrenia? Select all that apply: 1. Delusions 2. Hallucinations 3. Apathy 4. Blunted affect 5. Lack of motivation

A client with schizophrenia is admitted to the facility. When collecting data about the client, the nurse should document which symptoms as negative symptoms of schizophrenia? Select all that apply: 1. Delusions 2. Hallucinations 3. Apathy 4. Blunted affect 5. Lack of motivation Correct Answer: 3,4,5 RATIONALES: Negative symptoms of schizophrenia reflect the absence of normal characteristics. They include apathy, lack of motivation, blunted affect, poverty of speech, anhedonia (diminished capacity to experience pleasure), and antisocial behavior. Positive symptoms of schizophrenia include delusions and hallucinations. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Comprehension

A client with schizophrenia tells the nurse, "My intestines are rotted from the worms chewing on them." This statement indicates a: 1. delusion of persecution. 2. delusion of grandeur. 3. somatic delusion. 4. jealous delusion.

A client with schizophrenia tells the nurse, "My intestines are rotted from the worms chewing on them." This statement indicates a: 1. delusion of persecution. 2. delusion of grandeur. 3. somatic delusion. 4. jealous delusion. Correct Answer: 3 RATIONALES: 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. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Knowledge

A delusional client approaches the nurse, stating, "I am the Easter bunny," and insisting that the nurse refer to him as such. The belief appears to be fixed and unchanging. Which nursing interventions should the nurse implement when working with this client? Select all that apply: 1. Consistently use the client's name in interaction. 2. Smile at the humor of the situation. 3. Agree that the client is the Easter Bunny. 4. Logically point out why the client could not be the Easter Bunny. 5. Provide an as-needed medication. 6. Provide the client with structured activities.

A delusional client approaches the nurse, stating, "I am the Easter bunny," and insisting that the nurse refer to him as such. The belief appears to be fixed and unchanging. Which nursing interventions should the nurse implement when working with this client? Select all that apply: 1. Consistently use the client's name in interaction. 2. Smile at the humor of the situation. 3. Agree that the client is the Easter Bunny. 4. Logically point out why the client could not be the Easter Bunny. 5. Provide an as-needed medication. 6. Provide the client with structured activities. Correct Answer: 1,6 RATIONALES: Continued reality-based orientation is necessary, so it's appropriate to use the client's name in any interaction. Structured activities can help the client refocus and resolve his delusion. The nurse shouldn't contribute to the delusion by going along with the situation or smiling at the humor of the circumstances. Logical arguments and an as-needed medication aren't likely to change the client's beliefs. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Analysis

A schizophrenic client states, "I hear the voice of King Tut." Which response by the nurse would be therapeutic? 1. "I don't hear the voice, but I know you hear what sounds like a voice." 2. "You shouldn't focus on that voice." 3. "Don't worry about the voice as long as it doesn't belong to anyone real." 4. "King Tut has been dead for years."

A schizophrenic client states, "I hear the voice of King Tut." Which response by the nurse would be therapeutic? 1. "I don't hear the voice, but I know you hear what sounds like a voice." 2. "You shouldn't focus on that voice." 3. "Don't worry about the voice as long as it doesn't belong to anyone real." 4. "King Tut has been dead for years." Correct Answer: 1 RATIONALES: This response states reality about the client's hallucination. The other options aren't therapeutic. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Application

The nurse is caring for a client with schizophrenia who experiences auditory hallucinations. The client appears to be listening to someone who isn't visible. He gestures, shouts angrily, and stops shouting in mid-sentence. Which nursing intervention is appropriate ? 1. Approach the client and touch him to get his attention. 2. Encourage the client to go to his room where he'll experience fewer distractions. 3. Acknowledge that the client is hearing voices but make it clear that the nurse doesn't hear these voices. 4. Ask the client to describe what the voices are saying.

The nurse is caring for a client with schizophrenia who experiences auditory hallucinations. The client appears to be listening to someone who isn't visible. He gestures, shouts angrily, and stops shouting in mid-sentence. Which nursing intervention is appropriate ? 1. Approach the client and touch him to get his attention. 2. Encourage the client to go to his room where he'll experience fewer distractions. 3. Acknowledge that the client is hearing voices but make it clear that the nurse doesn't hear these voices. 4. Ask the client to describe what the voices are saying. Correct Answer: 3 RATIONALES: By acknowledging that the client hears voices, the nurse conveys acceptance of the client. By letting the client know that the nurse doesn't hear the voices, the nurse avoids reinforcing the hallucination. The nurse shouldn't touch the client with schizophrenia without advance warning. The hallucinating client may believe that the touch is a threat or act of aggression and respond violently. Being alone in his room encourages the client to withdraw and may promote more hallucinations. The nurse should provide an activity to distract the client. By asking the client what the voices are saying, the nurse is reinforcing the hallucination. The nurse should focus on the client's feelings, rather than the content of the hallucination. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Analysis

The nurse is caring for a client with schizophrenia. Which outcome should prompt a revision to the client's plan of care? 1. The client spends more time by himself. 2. The client doesn't engage in delusional thinking. 3. The client doesn't harm himself or others. 4. The client demonstrates the ability to meet his own self-care needs.

The nurse is caring for a client with schizophrenia. Which outcome should prompt a revision to the client's plan of care? 1. The client spends more time by himself. 2. The client doesn't engage in delusional thinking. 3. The client doesn't harm himself or others. 4. The client demonstrates the ability to meet his own self-care needs. Correct Answer: 1 RATIONALES: The client with schizophrenia is commonly socially isolated and withdrawn. Having the client spend more time by himself isn't a desirable outcome. The client's plan of care should be revised to reflect the outcome of spending more time with other clients and staff on the unit. The other options are desirable outcomes that don't require revisions to the client's plan of care. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Analysis

The nurse is developing a teaching plan for a client receiving clozapine (Clozaril). The nurse should stress the importance of which aspect of follow-up care? 1. Monthly EEGs 2. Cardiology consult 3. Echocardiogram 4. Routine complete blood count (CBC) with differential

The nurse is developing a teaching plan for a client receiving clozapine (Clozaril). The nurse should stress the importance of which aspect of follow-up care? 1. Monthly EEGs 2. Cardiology consult 3. Echocardiogram 4. Routine complete blood count (CBC) with differential Correct Answer: 4 RATIONALES: The client requires routine CBCs with differentials because clozapine can cause potentially fatal blood dyscrasia characterized by severe neutropenia. Although this adverse effect is rare, it's potentially fatal if not detected early. Monthly EEGs, a cardiology consult, and an echocardiogram aren't necessary follow-up measures for the client taking clozapine. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological therapies COGNITIVE LEVEL: Application

Which information is important for the nurse to include in a teaching plan for a schizophrenic client taking clozapine (Clozaril)? 1. Monthly blood tests will be necessary. 2. Report a sore throat or fever to the physician immediately. 3. Blood pressure must be monitored for hypertension. 4. Stop the medication when symptoms subside.

Which information is important for the nurse to include in a teaching plan for a schizophrenic client taking clozapine (Clozaril)? 1. Monthly blood tests will be necessary. 2. Report a sore throat or fever to the physician immediately. 3. Blood pressure must be monitored for hypertension. 4. Stop the medication when symptoms subside. Correct Answer: 2 RATIONALES: A sore throat and fever are indications of an infection caused by agranulocytosis, a potentially life-threatening complication of clozapine. Because of the risk of agranulocytosis, white blood cell (WBC) counts are necessary weekly, not monthly. If the WBC count drops below 3,000/μl, the medication must be stopped. Hypotension may occur in clients taking this medication. Warn the client to stand up slowly to avoid dizziness from orthostatic hypotension. The medication should be continued, even when symptoms have been controlled. If the medication must be stopped, it should be slowly tapered over 1 to 2 weeks and only under the supervision of a physician. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological therapies COGNITIVE LEVEL: Application