Chapter 4

Question 1

A newly admitted patient has the diagnosis of catatonic schizophrenia. Which behavior observed in the patient supports that diagnosis?

Answer 1

Maintains an immobilized state for hours

Question 2

What would be an appropriate short-term outcome for a patient diagnosed with residual schizophrenia who exhibits ambivalence?

Answer 2

Choose between two outfits to wear each morning.

Question 3

What is the priority nursing diagnosis for a catatonic patient?

Answer 3

Risk for deficient fluid volume

Question 4

Which nursing diagnosis is appropriate for a patient who insists being called Your Highness and demonstrates loosely associated thoughts?

Answer 4

Disturbed thought processes

Question 5

Which initial short-term outcome would be appropriate for a patient who was admitted expressing delusional thoughts?

Answer 5

Engage in reality-oriented conversation.

Question 6

Which assessment observation supports a patients diagnosis of disorganized schizophrenia?

Answer 6

Consistent inappropriate laughing

Question 7

Which of the following interventions should the nurse plan to use to reduce patient focus on delusional thinking?

Answer 7

Focusing on feelings suggested by the delusion

Question 8

A patient tried to gouge out his eye in response to auditory hallucinations commanding, If thine eye offends thee, pluck it out. The nurse would analyze this behavior as indicating:

Answer 8

Impaired impulse control

Question 9

An appropriate intervention for a patient with an identified nursing diagnosis of situational low self-esteem would be:

Answer 9

Engaging patient in activities designed to permit success

Question 10

A 19-year-old patient is admitted for the second time in 9 months and is acutely psychotic with a diagnosis of undifferentiated schizophrenia. The patient sits alone rubbing her arms and smiling. She tells the nurse her thoughts cause earthquakes and that the world is burning. The nurse assesses the primary deficit associated with the patients condition as:

Answer 10

Disturbed thinking

Question 11

A patient has been admitted with disorganized type schizophrenia. The nurse observes blunted affect and social isolation. He occasionally curses or calls another patient a jerk without provocation. The nurse asks the patient how he is feeling, and he responds, Everybody picks on me. They frobitz me. The patients communication exhibits:

Answer 11

A neologism

Question 12

A patient has been admitted with disorganized type schizophrenia. The nurse asks the patient how he is feeling, and he responds, Everybody picks on me. They frobitz me. The best response for the nurse to make would be:

Answer 12

Who do you mean when you say everybody?

Question 13

Which patient behavior would support the diagnosis of residual schizophrenia with negative symptoms?

Answer 13

Shows no emotion when telling the story of a sisters recent death

Question 14

By discharge, which outcome is appropriate for a patient who hears voices telling him he is evil?

Answer 14

Identify events that increase anxiety and promote hallucinations.

Question 15

Which response by the nurse would best assist a patient in de-escalating aggressive behavior?

Answer 15

Tell me whats going on

Question 16

A 34-year-old male admitted with catatonic schizophrenia has been mute and motionless for several days while at home prior to admission. He still appears stuporous in the hospital. Which nursing intervention would be an initial priority?

Answer 16

Assessing the patient for physical problems

Question 17

Which response is appropriate when a patients mother expresses guilt over causing my child to be schizophrenic?

Answer 17

New findings suggest this disorder is biological in nature.

Question 18

Which response demonstrates both empathy and understanding of the relationship genetics has to the development of schizophrenia in twins?

Answer 18

In fraternal twins, the chance of the other twin developing the disorder is quite small.

Question 19

The wife of a patient diagnosed with paranoid schizophrenia asks, Ive been told that my husbands illness is probably related to imbalanced brain chemicals. Can you be more specific? The response based on the dopamine hypothesis is:

Answer 19

An increase in the brain chemical dopamine explains the presence of delusions and hallucinations

Question 20

What is the basis for the reduction in disturbed thought processes when a patient is administered haloperidol (Haldol)?

Answer 20

Dopamine receptors are blocked, making dopamine less available

Question 21

During a treatment team meeting, the point is made that a patient with schizophrenia has recovered from the acute psychosis but continues to demonstrate apathy, avolition, and blunted affect. The nurse who relates these symptoms to serotonin (5HT2) excess will suggest that the patient receive:

Answer 21

Olanzapine (Zyprexa)

Question 22

What response would be anticipated when a patient who received chlorpromazine (Thorazine) for 15 years to treat schizophrenia is switched to Seroquel (quetiapine)?

Answer 22

Improvement in tardive dyskinesia

Question 23

A patient admitted with the diagnosis of schizophreniform disorder R/O organic pathology. Based on this information, the nurse can expect that the patient will:

Answer 23

Be scheduled for a magnetic resonance imaging (MRI) test

Question 24

In planning aftercare for a patient with schizophrenia and whose insurance benefits have been exhausted, the nurse who is concerned about overcoming negative symptoms will make provisions for the patient to have stimulation, structure, socialization, and support. Which option would best incorporate these factors?

Answer 24

Attending a psychosocial club

Question 25

A patient with catatonic schizophrenia has been standing with his left arm upraised and his right foot off the floor for the majority of the last 20 hours, eating only when allowed to eat standing up. Which nursing intervention has priority for this patient?

Answer 25

Assessing for lower extremity edema bid

Question 26

Which nursing action best addresses the needs of a paranoid patient who believes the food is poisoned?

Answer 26

Allowing the patient to select food from vending machines

Question 27

Prior to discharge, the nurse plans to teach the patient and family about relapse. Which items will the nurse include in the teaching?

Answer 27

Recognizing warning signs of relapse

Question 28

Because of the cognitive disturbances associated with schizophrenia, which technique will be useful as the nurse teaches a patient about self-management?

Answer 28

Teach material in small segments

Question 29

The wife of a patient newly diagnosed with paranoid schizophrenia is concerned that her husband will be this sick for the rest of his life. What information can the nurse provide to the wife?

Answer 29

This disorder generally responds well with treatment and follow-up.

Question 30

A patient is exhibiting auditory hallucinations in addition to being forgetful and easily confused. Which diagnosis does the nurse base this patients interventions on?

Answer 30

Impaired cognitive functioning

Question 31

A patient experiences intrusive, insulting auditory hallucinations. Which independent behavioral technique can the nurse teach the patient to employ when the voices are troublesome?

Answer 31

Sing or whistle to compete with the voices.

Question 32

A patient with schizophrenia tells the nurse as they sit in the day room, I hear voices telling me bad things. The most therapeutic response the nurse can make is:

Answer 32

I believe you hear voices, but I dont hear them myself.

Question 33

A patient tells the nurse, When Im in the day room, I hear people whispering about me, and that makes me want to punch them. What direction will the nurse provide the staff regarding interacting with this patient?

Answer 33

Treat this patient matter-of-factly. Be direct; don't talk about him or others in his presence.

Question 34

A patient with schizophrenia is medication compliant and has well-controlled symptoms. He has, however, never been successful in holding a job because of poor social skills and lack of understanding of basic job skills. The nurse case manager should consider referring the patient:

Answer 34

For psychosocial rehabilitation

Question 35

A patient prescribed an antipsychotic medication develops a high fever, unstable blood pressure, and muscle rigidity. Her next dose of medication is due. The nurse should:

Answer 35

Hold the medication and immediately describe the patients symptoms to the doctor.

Question 36

Which interventions will the nurse implement to preserve milieu safety when a patient becomes agitated? Select all that apply. a. Project confidence and control. b. Provide a show of force when appropriate. c. Ask the agitated patient why they are feeling so aggressive. d. Move to within 5 feet of the patient to help contain their movement.

Answer 36

A, B, E

Question 37

Which interventions will the nurse implement to assure effective staff crises management skills? Select all that apply. a. Schedule regular staff crises simulations. b. Encourage the staff to discuss the details of unit crises. c. Attempt to identify staff who are ineffective during crises. d. Review documentation that describe the details of unit crises. e. Review unit crises management policies for needed updates.

Answer 37

A, B, D, E