Chapter 24 Flashcards
A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client’s safety?
B. Note escalating behaviors and intervene immediately
A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be taught by the nurse?
C. How to make eye contact when communicating
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.”
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?
C. “Focus on the feelings generated by the hallucinations and present reality.”
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?
D. Delusions of reference
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?
B. “The client is expressing a neologism.”
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?
B. Delusions of influence
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?
C. “I’m sure the voices sound scary. I don’t hear any voices speaking.”
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?
C. Risk for violence: directed toward others
Which nursing intervention would be most appropriate when caring for an acutely agitated client with paranoia?
D. Provide personal space to respect the client’s boundaries.
Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia?
B. Being reliable, honest, and consistent during interactions.
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?
C. Command hallucinations; warn the psychiatrist
Which statement should indicate to a nurse that an individual is experiencing a delusion?
A. “There’s an alien growing in my liver.”
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?
C. Risperidone (Risperdal) to address the positive symptom
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?
C. Restlessness and muscle rigidity
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?
B. Paranoia, neologisms, and echolalia are positive symptoms of schizophrenia.
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?
D. Tardive dyskinesia, treated by discontinuing antipsychotic medications
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 105F (40.5C). The nurse identifies these symptoms as which of the following conditions?
A. Neuroleptic malignant syndrome
A client diagnosed with schizophrenia takes an antipsychotic agent daily. Which assessment finding should a nurse immediately report to the client’s attending psychiatrist?
C. Temperature of 104F (40C)
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?
C. “Rise slowly when you change position from lying to sitting or sitting to standing.”
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
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
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?
D. Thioridazine (Mellaril), because of cross-sensitivity among phenothiazines
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?
B. Risk for other-directed violence R/T yelling accusations
