Deck 24: Schizophrenia Spectrum and Other Psychotic Disorders

Question 1

A nurse is assessing a client diagnosed with schizophrenia.The nurse asks the client,"Do you receive special messages from certain sources,such as the television or radio?" Which potential symptom of this disorder is the nurse assessing?

A) Thought insertion
B) Paranoia
C) Magical thinking
D) Delusions of reference

Answer 1

Delusions of reference

Question 2

Which nursing intervention would be most appropriate when caring for an acutely agitated client with paranoia?

A) Provide neon lights and soft music.
B) Maintain continual eye contact throughout the interview.
C) Use therapeutic touch to increase trust and rapport.
D) Provide personal space to respect the client's boundaries.

Answer 2

Provide personal space to respect the client's boundaries.

Question 3

A client diagnosed with schizophrenia states,"Can't you hear him? It's the devil.He's telling me I'm going to hell." Which is the most appropriate nursing reply?

A) "Did you take your medicine this morning?"
B) "You are not going to hell. You are a good person."
C) "I'm sure the voices sound scary. I don't hear any voices speaking."
D) "The devil only talks to people who are receptive to his influence."

Answer 3

"I'm sure the voices sound scary. I don't hear any voices speaking."

Question 4

Parents ask a nurse how they should reply when their child,diagnosed with schizophrenia,tells them that voices command him to harm others.Which is the appropriate nursing reply?

A) "Tell him to stop discussing the voices."
B) "Ignore what he is saying, while attempting to discover the underlying cause."
C) "Focus on the feelings generated by the hallucinations and present reality."
D) "Present objective evidence that the voices are not real."

Question 5

Which statement should indicate to a nurse that an individual is experiencing a delusion?

A) "There's an alien growing in my liver."
B) "I see my dead husband everywhere I go."
C) "The IRS may audit my taxes."
D) "I'm not going to eat my food. It smells like brimstone."

Question 6

A client who is admitted to the inpatient psychiatric unit and is taking Thorazine presents to the nurse with severe muscle rigidity,tachycardia,and a temperature of 105°F (40.5°C).The nurse identifies these symptoms as which of the following conditions?

A) Neuroleptic malignant syndrome
B) Tardive dyskinesia
C) Acute dystonia
D) Agranulocytosis

Question 7

An elderly client diagnosed with schizophrenia takes an antipsychotic and a beta-adrenergic blocking agent (propranolol)for hypertension.Understanding the combined side effects of these drugs,the nurse would most appropriately make which statement?

A) "Make sure you concentrate on taking slow, deep, cleansing breaths."
B) "Watch your diet and try to engage in some regular physical activity."
C) "Rise slowly when you change position from lying to sitting or sitting to standing."
D) "Wear sunscreen and try to avoid midday sun exposure."

Question 8

During an admission assessment,a nurse asks a client diagnosed with schizophrenia,"Have you ever felt that certain objects or persons have control over your behavior?" The nurse is assessing for which type of thought disruption?

A) Delusions of persecution
B) Delusions of influence
C) Delusions of reference
D) Delusions of grandeur

Question 9

A client diagnosed with schizoaffective disorder is admitted for social skills training.Which information should be taught by the nurse?

A) The side effects of medications
B) Deep breathing techniques to decrease stress
C) How to make eye contact when communicating
D) How to be a leader

Question 10

A client is diagnosed with schizophrenia.A physician orders haloperidol (Haldol),50 mg bid; benztropine (Cogentin),1 mg prn; and zolpidem (Ambien),10 mg HS.Which client behavior would warrant the nurse to administer benztropine?

A) Tactile hallucinations
B) Tardive dyskinesia
C) Restlessness and muscle rigidity
D) Reports of hearing disturbing voices

Question 11

A client diagnosed with schizophrenia tells a nurse,"The 'Shopatouliens' took my shoes out of my room last night." Which is an appropriate charting entry to describe this client's statement?

A) "The client is experiencing command hallucinations."
B) "The client is expressing a neologism."
C) "The client is experiencing a paranoia."
D) "The client is verbalizing a word salad."

Question 12

A client diagnosed with schizophrenia,who has been taking antipsychotic medication for the last 5 months,presents in an emergency department (ED)with uncontrollable tongue movements,stiff neck,and difficulty swallowing.The nurse would expect the physician to recognize which condition and implement which treatment?

A) Neuroleptic malignant syndrome, treated by discontinuing antipsychotic medications
B) Agranulocytosis, treated by administration of clozapine (Clozaril)
C) Extrapyramidal symptoms, treated by administration of benztropine (Cogentin)
D) Tardive dyskinesia, treated by discontinuing antipsychotic medications

Question 13

A 16-year-old client diagnosed with schizophrenia experiences command hallucinations to harm others.The client's parents ask a nurse,"Where do the voices come from?" Which is the appropriate nursing reply?

A) "Your child has a chemical imbalance of the brain, which leads to altered thoughts."
B) "Your child's hallucinations are caused by medication interactions."
C) "Your child has too little serotonin in the brain, causing delusions and hallucinations."
D) "Your child's abnormal hormonal changes have precipitated auditory hallucinations."

Question 14

Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia?

A) Establishing personal contact with family members.
B) Being reliable, honest, and consistent during interactions.
C) Sharing limited personal information.
D) Sitting close to the client to establish rapport.

Question 15

A paranoid client presents with bizarre behaviors,neologisms,and thought insertion.Which nursing action should be prioritized to maintain this client's safety?

A) Assess for medication noncompliance
B) Note escalating behaviors and intervene immediately
C) Interpret attempts at communication
D) Assess triggers for bizarre, inappropriate behaviors

Question 16

A nurse is caring for a client who is experiencing a flat affect,paranoia,anhedonia,anergia,neologisms,and echolalia.Which statement correctly differentiates the client's positive and negative symptoms of schizophrenia?

A) Paranoia, anhedonia, and anergia are positive symptoms of schizophrenia.
B) Paranoia, neologisms, and echolalia are positive symptoms of schizophrenia.
C) Paranoia, anergia, and echolalia are negative symptoms of schizophrenia.
D) Paranoia, flat affect, and anhedonia are negative symptoms of schizophrenia.

Question 17

A client diagnosed with schizophrenia is slow to respond and appears to be listening to unseen others.Which medication should a nurse expect a physician to order to address this type of symptom?

A) Haloperidol (Haldol) to address the negative symptom
B) Clonazepam (Klonopin) to address the positive symptom
C) Risperidone (Risperdal) to address the positive symptom
D) Clozapine (Clozaril) to address the negative symptom

Question 18

A client diagnosed with brief psychotic disorder tells a nurse about voices telling him to kill the president.Which nursing diagnosis should the nurse prioritize for this client?

A) Disturbed sensory perception
B) Altered thought processes
C) Risk for violence: directed toward others
D) Risk for injury

Question 19

A client diagnosed with schizophrenia takes an antipsychotic agent daily.Which assessment finding should a nurse immediately report to the client's attending psychiatrist?

A) Respirations of 22 beats/minute
B) Weight gain of 8 pounds in 2 months
C) Temperature of 104°F (40°C)
D) Excessive salivation

Question 20

A client diagnosed with schizophrenia states,"My psychiatrist is out to get me.I'm sad that the voice is telling me to stop him." What symptom is the client exhibiting,and what is the nurse's legal responsibility related to this symptom?

A) Magical thinking; administer an antipsychotic medication
B) Persecutory delusions; orient the client to reality
C) Command hallucinations; warn the psychiatrist
D) Altered thought processes; call an emergency treatment team meeting

Question 21

A college student has quit attending classes,isolates self because of hearing voices,and yells accusations at fellow students.Based on this information,which nursing diagnosis should the nurse prioritize?

A) Altered thought processes R/T hearing voices AEB increased anxiety
B) Risk for other-directed violence R/T yelling accusations
C) Social isolation R/T paranoia AEB absence from classes
D) Risk for self-directed violence R/T depressed mood

Question 22

Which of the following components should a nurse recognize as an integral part of a rehabilitative program when planning care for clients diagnosed with schizophrenia? Select all that apply.

A) Group therapy
B) Medication management
C) Deterrent therapy
D) Supportive family therapy
E) Social skills training

Question 23

A nurse is administering risperidone (Risperdal)to a client diagnosed with schizophrenia.The therapeutic effect of this medication would most effectively address which of the following symptoms? Select all that apply.

A) Somatic delusions
B) Social isolation
C) Gustatory hallucinations
D) Flat affect
E) Clang associations

Question 24

If clozapine (Clozaril)therapy is being considered,the nurse should evaluate which laboratory test to establish a baseline for comparison in order to recognize a potentially life-threatening side effect?

A) White blood cell count
B) Liver function studies
C) Creatinine clearance
D) Blood urea nitrogen

Question 25

A client has been recently admitted to an inpatient psychiatric unit.Which intervention should the nurse plan to use to reduce the client's focus on delusional thinking?

A) Present evidence that supports the reality of the situation
B) Focus on feelings suggested by the delusion
C) Address the delusion with logical explanations
D) Explore reasons why the client has the delusion

Question 26

A newly admitted client has taken thioridazine (Mellaril)for 2 years,with good symptom control.Symptoms exhibited on admission included paranoia and hallucinations.The nurse should recognize which potential cause for the return of these symptoms?

A) The client has developed tolerance to the antipsychotic medication.
B) The client has not taken the medication with food.
C) The client has not taken the medication as prescribed.
D) The client has combined alcohol with the medication.

Question 27

A client states,"I hear voices that tell me that I am evil." Which outcome related to these symptoms should the nurse expect this client to accomplish by discharge?

A) The client will verbalize the reason the voices make derogatory statements.
B) The client will not hear auditory hallucinations.
C) The client will identify events that increase anxiety and illicit hallucinations.
D) The client will positively integrate the voices into the client's personality structure.

Question 28

During an admission assessment,a nurse notes that a client diagnosed with schizophrenia has allergies to penicillin,prochlorperazine (Compazine),and bee stings.On the basis of this assessment data,which antipsychotic medication would be contraindicated?

A) Haloperidol (Haldol), because it is used only in elderly patients
B) Clozapine (Clozaril), because of a cross-sensitivity to penicillin
C) Risperidone (Risperdal), because it exacerbates symptoms of depression
D) Thioridazine (Mellaril), because of cross-sensitivity among phenothiazines

Question 29

A client diagnosed with schizophrenia is prescribed clozapine (Clozaril).Which client symptoms related to the side effects of this medication should prompt a nurse to intervene immediately?

A) Sore throat, fever, and malaise
B) Akathisia and hypersalivation
C) Akinesia and insomnia
D) Dry mouth and urinary retention

Question 30

Laboratory results reveal elevated levels of prolactin in a client diagnosed with schizophrenia.When assessing the client,the nurse should expect to observe which symptoms? Select all that apply.

A) Apathy
B) Social withdrawal
C) Anhedonia
D) Galactorrhea
E) Gynecomastia