Psychotic Disorders REVIEWER.doc

8/14/2019 Psychotic Disorders REVIEWER.doc

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Questions and Rationale on Psychotic Disorders

1. A psychotic client reports to the evening nurse that the day nurse put somethingsuspicious in his water with his medication. The nurse replies, "Youre worried a!out

your medication" The nurses communication is#

A. an e$ample o% presenting reality.&. rein%orcing the clients delusions.C. focusing on emotional content.

D. a nontherapeutic techni'ue called mind reading.

Rationale# The nurse should help the client %ocus on the emotional content rather

than delusional material. Presenting reality isnt help%ul !ecause it can lead tocon%rontation and disengagement. Agreeing with the client and supporting his !elie%s

are rein%orcing delusions. (ind reading isnt therapeutic.

). A client is admitted to the inpatient unit o% the mental health center with adiagnosis o% paranoid schi*ophrenia. +es shouting that the government o% rance is

trying to assassinate him. -hich o% the %ollowing responses is most appropriate

A. " thin/ youre wrong. rance is a %riendly country and an ally o% the 0nitedtates. Their government wouldnt try to /ill you."

B. "I find it hard to believe that a foreign government or anyone else istrying to hurt you. You must feel frightened by this."

2. "Youre wrong. 3o!ody is trying to /ill you."D. "A %oreign government is trying to /ill you Please tell me more a!out it."

Rationale# Responses should %ocus on reality while ac/nowledging the clients

%eelings. Arguing with the client or denying his !elie% isnt therapeutic. Arguing canalso inhi!it development o% a trusting relationship. 2ontinuing to tal/ a!out delusions

may aggravate the psychosis. As/ing the client i% a %oreign government is trying to

/ill him may increase his an$iety level and can rein%orce his delusions.

4. Propranolol 5nderal6 is used in the mental health setting to manage which o% the%ollowing conditions

A. Antipsychotic-induced akathisia and anxiety

&. The manic phase o% !ipolar illness as a mood sta!ili*er

2. Delusions %or clients su%%ering %rom schi*ophreniaD. 7!sessive8compulsive disorder 572D6 to reduce ritualistic !ehavior

Rationale# Propranolol is a potent !eta8adrenergic !loc/er and produces a sedating

e%%ect9 there%ore, its used to treat antipsychotic induced a/athisia and an$iety.:ithium 5:itho!id6 is used to sta!ili*e clients with !ipolar illness. Antipsychotics are

used to treat delusions. ome antidepressants have !een e%%ective in treating 72D.

;. A client with !orderline personality disorder !ecomes angry when he is told thattodays psychotherapy session with the nurse will !e delayed 4< minutes !ecause o%

an emergency. -hen the session %inally !egins, the client e$presses anger. -hichresponse !y the nurse would !e most help%ul in dealing with the clients anger

A. "% it had !een your emergency, would have made the other client wait."

&. " /now its %rustrating to wait. m sorry this happened."


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C. "You had to ait. Can e talk about ho this is making you feel rightno!"

D. " really care a!out you and ll never let this happen again."

Rationale# This response may di%%use the clients anger !y helping to maintain atherapeutic relationship and addressing the clients %eelings. 7ption A wouldnt

address the clients anger. 7ption & is incorrect !ecause the client with a !orderlinepersonality disorder !lames others %or things that happen, so apologi*ing rein%orcesthe clients misconceptions. The nurse cant promise that a delay will never occur

again, as in option D, !ecause such matters are outside the nurses control.

=. +ow soon a%ter chlorproma*ine 5Thora*ine6 administration should the nurse

e$pect to see a clients delusional thoughts and hallucinations eliminated

A. everal minutes&. everal hours

2. everal days. #everal eeks

Rationale# Although most phenothia*ines produce some e%%ects within minutes tohours, their antipsychotic e%%ects may ta/e several wee/s to appear.

>. A client receiving haloperidol 5+aldol6 complains o% a sti%% ?aw and di%%icultyswallowing. The nurses %irst action is to#

A. reassure the client and administer as needed lora*epam 5Ativan6 .(.

B. administer as needed dose of ben$tropine %Cogentin& I.'. as ordered.2. administer as needed dose o% !en*tropine 52ogentin6 !y mouth as ordered.

D. administer as needed dose o% haloperidol 5+aldol6 !y mouth.

Rationale# The client is most li/ely su%%ering %rom muscle rigidity due to haloperidol.

.(. !en*tropine should !e administered to prevent asphy$ia or aspiration.:ora*epam treats an$iety, not e$trapyramidal e%%ects. Another dose o% haloperidol

would increase the severity o% the reaction.

@. A client with a diagnosis o% paranoid schi*ophrenia comments to the nurse, "+owdo /now what is really in those pills" -hich o% the %ollowing is the !est response

A. ay, "You /now its your medicine."B. Allo him to open the individual rappers of the medication.

2. ay, "Dont worry a!out what is in the pills. ts what is ordered."D. gnore the comment !ecause its pro!a!ly a ?o/e.

Rationale# 7ption & is correct !ecause allowing a paranoid client to open his

medication can help reduce suspiciousness. 7ption A is incorrect !ecause the clientdoesnt /now that its his medication and hes o!viously suspicious. Telling the client

not to worry or ignoring the comment isnt supportive and doesnt o%%er reassurance.

. The nurse is caring %or a client with schi*ophrenia who e$periences auditoryhallucinations. The client appears to !e listening to someone who isnt visi!le. +e

gestures, shouts angrily, and stops shouting in mid8sentence. -hich nursingintervention is the most appropriate


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his room would increase, rather than decrease, the hallucinations.

11. A client with catatonic schi*ophrenia is mute, cant per%orm activities o% dailyliving, and stares out the window %or hours. -hat is the nurses %irst priority

A. Assist the client ith feeding.

&. Assist the client with showering.2. Reassure the client a!out sa%ety.D. Bncourage sociali*ation with peers.

Rationale# According to (aslows hierarchy o% needs, the need %or %ood is among themost important. 7ther needs, in order o% decreasing importance, include hygiene,

sa%ety, and a sense o% !elonging.

1). A client tells the nurse that the television newscaster is sending a secretmessage to her. The nurse suspects the client is e$periencing#

A. a delusion.

&. %light o% ideas.

C. ideas of reference.D. a hallucination.

Rationale# deas o% re%erence re%ers to the mista/en !elie% that neutral stimuli havespecial meaning to the individual such as the television newscaster sending a

message directly to the individual. A delusion is a %alse !elie%. light o% ideas is aspeech pattern in which the client s/ips %rom one unrelated su!?ect to another. A

hallucination is a sensory perception, such as hearing voices and seeing o!?ects, thatonly the client e$periences.

14. The nurse /nows that the physician has ordered the li'uid %orm o% the drug

chlorproma*ine 5Thora*ine6 rather than the ta!let %orm !ecause the li'uid#

A. has a more predictable onset of action.

&. produces %ewer anticholinergic e%%ects.2. produces %ewer drug interactions.

D. has a longer duration o% action.

Rationale# A li'uid phenothia*ine preparation will produce e%%ects in ) to ; hours. The

onset with ta!lets is unpredicta!le.

1;. A client who has !een hospitali*ed with disorgani*ed type schi*ophrenia %or years cant complete activities o% daily living 5AD:s6 without sta%% direction and

assistance. The nurse %ormulates a nursing diagnosis o% el%8care de%icient#Dressinggrooming related to ina!ility to %unction without assistance. -hat is an

appropriate goal %or this client

A. "2lient will !e a!le to complete AD:s independently within 1 month."&. "2lient will !e a!le to complete AD:s with only ver!al encouragement within 1

month."C. "Client ill be able to complete A+s ith assistance in organi$ing

grooming items and clothing ithin , month."D. "2lient will !e a!le to complete AD:s with complete assistance within 1 month."


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Rationale# The clients disorgani*ed personality and history o% hospitali*ation havea%%ected the a!ility to per%orm sel%8care activities. nterventions should !e directed at

helping the client complete AD:s with the assistance o% sta%% mem!ers, who canprovide needed structure !y helping the client select grooming items and clothing.

This goal promotes realistic independence. As the client improves and achieves theesta!lished goal, the nurse can set new goals that %ocus on the client completing

AD:s with only ver!al encouragement and, ultimately, completing themindependently. The clients condition doesnt indicate a need %or complete assistance,which would only %oster dependence.

1=. The nurse is planning care %or a client admitted to the psychiatric unit with adiagnosis o% paranoid schi*ophrenia. -hich nursing diagnosis should receive the

highest priority

A. isk for violence toard self or others&. m!alanced nutrition# :ess than !ody re'uirements

2. ne%%ective %amily copingD. mpaired ver!al communication

Rationale# &ecause o% such %actors as suspiciousness, an$iety, and hallucinations, theclient with paranoid schi*ophrenia is at ris/ %or violence toward himsel% or others.The other options are also appropriate nursing diagnoses !ut should !e addressed

a%ter the sa%ety o% the client and those around him is esta!lished.

1>. The nurse is preparing %or the discharge o% a client who has !een hospitali*ed %orparanoid schi*ophrenia. The clients hus!and e$presses concern over whether his

wi%e will continue to ta/e her daily prescri!ed medication. The nurse should in%ormhim that#

A. his concern is valid !ut his wi%e is an adult and has the right to ma/e her own

decisions.

&. he can easily mi$ the medication in his wi%es %ood i% she stops ta/ing it.C. his ife can be given a long-acting medication that is administered every

, to eeks.D. his wi%e /nows she must ta/e her medication as prescri!ed to avoid %uture

hospitali*ations.

Rationale# :ong8acting psychotropic drugs can !e administered !y depot in?ection

every 1 to ; wee/s. These agents are use%ul %or noncompliant clients !ecause theclient receives the in?ection at the outpatient clinic. A client has the right to re%use

medication, !ut this issue isnt the %ocus o% discussion at this time. (edication shouldnever !e hidden in %ood or drin/ to tric/ the client into ta/ing it9 !esides destroying

the clients trust, doing so would place the client at ris/ %or overmedication orundermedication !ecause the amount administered is hard to determine. Assuming

the client /nows she must ta/e the medication to avoid %uture hospitali*ations would!e unrealistic.

1@. &en*tropine 52ogentin6 is used to treat the e$trapyramidal e%%ects induced !y

antipsychotics. This drug e$erts its e%%ect !y#

A. decreasing the an$iety causing muscle rigidity.B. blocking the cholinergic activity in the central nervous system %C/#&.

2. increasing the level o% acetylcholine in the 23.


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D. increasing norepinephrine in the 23.

Rationale# 7ption & is the action o% 2ogentin. An$iety doesnt cause e$trapyramidale%%ects. 7veractivity o% acetylcholine and lower levels o% dopamine are the causes o%

e$trapyramidal e%%ects. &en*tropine doesnt increase norepinephrine in the 23.

1. A client is admitted to the inpatient unit o% the mental health center with adiagnosis o% paranoid schi*ophrenia. +es shouting that the government o% rance istrying to assassinate him. -hich o% the %ollowing responses is most appropriate

A. " thin/ youre wrong. rance is a %riendly country and an ally o% the 0nitedtates. Their government wouldnt try to /ill you."

B. "I find it hard to believe that a foreign government or anyone else istrying to hurt you. You must feel frightened by this."

2. "Youre wrong. 3o!ody is trying to /ill you."D. "A %oreign government is trying to /ill you Please tell me more a!out it."

Rationale# Responses should %ocus on reality while ac/nowledging the clients

%eelings. Arguing with the client or denying his !elie% isnt therapeutic. Arguing can

also inhi!it development o% a trusting relationship. 2ontinuing to tal/ a!out delusionsmay aggravate the psychosis. As/ing the client i% a %oreign government is trying to/ill him may increase his an$iety level and can rein%orce his delusions.

1C. A dopamine receptor agonist such as !romocriptine 5Parlodel6 relieves muscle

rigidity caused !y antipsychotic medication !y#

A. !loc/ing dopamine receptors in the central nervous system 5236.&. !loc/ing acetylcholine in the 23.

2. activating norepinephrine in the 23.. activating dopamine receptors in the C/#.

Rationale# B$trapyramidal e%%ects and the muscle rigidity induced !y antipsychoticmedications are caused !y a low level o% dopamine. Dopamine receptor agonists

stimulate dopamine receptors and there!y reduce rigidity. They dont a%%ectnorepinephrine or acetylcholine.

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laughing, yelling, and tal/ing to hersel%. This !ehavior is characteristic o%#

A. delusion.&. looseness o% association.

2. illusion.. hallucination.

Rationale# Auditory hallucination, in which one hears voices when no e$ternal stimulie$ist, is common in schi*ophrenic clients. uch !ehaviors as laughing, yelling, and

tal/ing to onesel% suggest such a hallucination. Delusions, also common in

schi*ophrenia, are %alse !elie%s or ideas that arise without e$ternal stimuli. 2lientswith schi*ophrenia may e$hi!it looseness o% association, a pattern o% thin/ing and

communicating in which ideas arent clearly lin/ed to one another. llusion is a lesssevere perceptual distur!ance in which the client misinterprets actual e$ternal

stimuli. llusions are rarely associated with schi*ophrenia.

)). -hich o% the %ollowing medications would the nurse e$pect the physician to orderto reverse a dystonic reaction

A. prochlorpera*ine 52ompa*ine6B. diphenhydramine %Benadryl&2. haloperidol 5+aldol6

D. mida*olam 5Eersed6

Rationale# Diphenhydramine, )= to =< mg .(. or .E., would 'uic/ly reverse thiscondition. Prochlorpera*ine and haloperidol are !oth capa!le o% causing dystonia, not

reversing it. (ida*olam would ma/e this client drowsy.

)4. A schi*ophrenic client states, " hear the voice o% Fing Tut." -hich response !ythe nurse would !e most therapeutic

A. "I don(t hear the voice0 but I kno you hear hat sounds like a voice."&. "You shouldnt %ocus on that voice."

2. "Dont worry a!out the voice as long as it doesnt !elong to anyone real."D. "Fing Tut has !een dead %or years."

Rationale# This response states reality a!out the clients hallucination. The other

options are ?udgmental, %lippant, or dismissive.

);. A psychotic client reports to the evening nurse that the day nurse put something

suspicious in his water with his medication. The nurse replies, "Youre worried a!outyour medication" The nurses communication is#

A. an e$ample o% presenting reality.

&. rein%orcing the clients delusions.C. focusing on emotional content.

D. a nontherapeutic techni'ue called mind reading.

Rationale# The nurse should help the client %ocus on the emotional content ratherthan delusional material. Presenting reality isnt help%ul !ecause it can lead to

con%rontation and disengagement. Agreeing with the client and supporting his !elie%sare rein%orcing delusions. (ind reading isnt therapeutic.


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)=. The nurse is caring %or a client with schi*ophrenia who e$periences auditoryhallucinations. The client appears to !e listening to someone who isnt visi!le. +e

gestures, shouts angrily, and stops shouting in mid8sentence. -hich nursingintervention is the most appropriate

A. Approach the client and touch him to get his attention.

&. Bncourage the client to go to his room where hell e$perience %ewer distractions.C. Acknoledge that the client is hearing voices but make it clear that thenurse doesn(t hear these voices.

D. As/ the client to descri!e what the voices are saying

Rationale# &y ac/nowledging that the client hears voices, the nurse conveys

acceptance o% the client. &y letting the client /now that the nurse doesnt hear thevoices, the nurse avoids rein%orcing the hallucination. The nurse shouldnt touch the

client with schi*ophrenia without advance warning. The hallucinating client may!elieve that the touch is a threat or act o% aggression and respond violently. &eing

alone in his room encourages the client to withdraw and may promote morehallucinations. The nurse should provide an activity to distract the client. &y as/ing

the client what the voices are saying, the nurse is rein%orcing the hallucination. The

nurse should %ocus on the clients %eelings, rather than the content o% thehallucination.

)>. A client has !een receiving chlorproma*ine 5Thora*ine6, an antipsychotic, to treathis psychosis. -hich %indings should alert the nurse that the client is e$periencing

pseudopar/insonism

A. Restlessness, di%%iculty sitting still, and pacing&. nvoluntary rolling o% the eyes

C. 1remors0 shuffling gait0 and masklike faceD. B$tremity and nec/ spasms, %acial grimacing, and ?er/y movements

Rationale# Pseudopar/insonism may appear 1 to = days a%ter starting anantipsychotic and may also include drooling, rigidity, and "pill rolling." A/athisia may

occur several wee/s a%ter starting antipsychotic therapy and consists o% restlessness,di%%iculty sitting still, and %idgeting. An oculogyric crisis is recogni*ed !y

uncontrolla!le rolling !ac/ o% the eyes and, along with dystonia, should !econsidered an emergency. Dystonia may occur minutes to hours a%ter receiving an

antipsychotic and may include e$tremity and nec/ spasms, ?er/y muscle movements,

and %acial grimacing.

)@. or several years, a client with chronic schi*ophrenia has received 1< mg o%%luphena*ine hydrochloride 5Proli$in6 !y mouth %our times per day. 3ow the client

has a temperature o% 1


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increase the clients %luid inta/e.

Rationale# (alignant neuroleptic syndrome is a dangerous adverse e%%ect o%neuroleptic drugs such as %luphena*ine. The nurse should withhold the ne$t dose,

noti%y the physician, and continue to monitor vital signs. Although an antipyreticagent may !e used to reduce %ever, increased %luid inta/e is contraindicated !ecause

it may increase the clients %luid volume %urther, raising !lood pressure even higher.

). A schi*ophrenic client with delusions tells the nurse, "There is a man wearing a

red coat whos out to get me." The client e$hi!its increasing an$iety when %ocusing

on the delusions. -hich o% the %ollowing would !e the !est response

A. "1his sub3ect seems to be troubling you. +et(s alk to the activity room."&. "Descri!e the man whos out to get you. -hat does he loo/ li/e"

2. "There is no reason to !e a%raid o% that man. This hospital is very secure."D. "There is no need to !e concerned with a man who isnt even real."

Rationale# This remar/ distracts the client %rom the delusion !y engaging the client in

a less threatening or more com%orting activity at the %irst sign o% an$iety. The nurse

should rein%orce reality and discourage the %alse !elie%. The other options %ocus onthe content o% the delusion rather than the meaning, %eeling, or intent that itprovo/es.

)C. mportant teaching %or women in their child!earing years who are receiving

antipsychotic medications includes which o% the %ollowing

A. 7ccurrence o% increased li!ido due to medication adverse e%%ects&. ncreased incidence o% dysmenorrhea while ta/ing the drug

C. Continuing previous use of contraception during periods of amenorrheaD. nstruction that amenorrhea is irreversi!le

Rationale# -omen may e$perience amenorrhea, which is reversi!le, while ta/ingantipsychotics. Amenorrhea doesnt indicate cessation o% ovulation9 there%ore, the

client can still !ecome pregnant. The client should !e instructed to continuecontraceptive use even when e$periencing amenorrhea. Dysmenorrhea isnt an

adverse e%%ect o% antipsychotics, and li!ido generally decreases !ecause o% thedepressant e%%ect.

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41. -hat medication would pro!a!ly !e ordered %or the acutely aggressive

schi*ophrenic client

A. chlorproma*ine 5Thora*ine6&. haloperidol 5+aldol6

2. lithium car!onate 5:ithonate6D. amitriptyline 5Blavil6

Rationale# +aloperidol administered .(. or .E. is the drug o% choice %or acute

aggressive psychotic !ehavior. 2hlorproma*ine is also an antipsychotic drug9however, it causes more pronounced sedation than haloperidol. :ithium car!onate is

use%ul in !ipolar or manic disorder, and amitriptyline is used %or depression.

4). A client is admitted with a diagnosis o% schi*otypal personality disorder. -hichsigns would this client e$hi!it during social situations

A. Aggressive !ehavior

B. 4aranoid thoughts

2. Bmotional a%%ectD. ndependence needs

Rationale# 2lients with schi*otypal personality disorder e$perience e$cessive socialan$iety that can lead to paranoid thoughts. Aggressive !ehavior is uncommon,

although these clients may e$perience agitation with an$iety. Their !ehavior isemotionally cold with a %lattened a%%ect, regardless o% the situation. These clients

demonstrate a reduced capacity %or close or dependent relationships.

44. During the initial interview, a client with schi*ophrenia suddenly turns to theempty chair !eside him and whispers, "3ow ?ust leave. told you to stay home.

There isnt enough wor/ here %or !oth o% usI" -hat is the nurses !est initial

response

A. "2hen people are under stress0 they may see things or hear things thatothers don(t. Is that hat 3ust happened!"

&. "m having a di%%icult time hearing you. Please loo/ at me when you tal/."2. "There is no one else in the room. -hat are you doing"

D. "-ho are you tal/ing to Are you hallucinating"

Rationale# This response ma/es the client %eel that e$periencing hallucinations is

accepta!le and promotes an open, therapeutic relationship. Directing the client toloo/ at the nurse wouldnt address the o!vious issue o% the hallucination.

2on%rontational approaches, such as in options 2 and D, are li/ely to elicit anunin%ormative or negative response.

4;. The de%inition o% nihilistic delusions is#

A. a %alse !elie% a!out the %unctioning o% the !ody.

&. !elie% that the !ody is de%ormed or de%ective in a speci%ic way.C. false ideas about the self0 others0 or the orld

D. the ina!ility to carry out motor activities.

Rationale# 3ihilistic delusions are %alse ideas a!out the sel%, others, or the world.


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omatic delusions involve a %alse !elie% a!out the %unctioning o% the !ody. &odydysmorphic disorder is characteri*ed !y a !elie% that the !ody is de%ormed or

de%ective in a speci%ic way. Apra$ia is the ina!ility to carry out motor activities.

4=. A client whos ta/ing antipsychotic medication develops a very high temperature,severe muscle rigidity, tachycardia, and rapid deterioration in mental status. The

nurse suspects what complication o% antipsychotic therapy

A. Agranulocytosis

&. B$trapyramidal e%%ects

2. Anticholinergic e%%ects. /euroleptic malignant syndrome %/'#&

Rationale# A rare !ut potentially %atal condition o% antipsychotic medication is called

3(. t generally starts with an elevated temperature and severe e$trapyramidale%%ects. Agranulocytosis is a !lood disorder. Anticholinergic e%%ects include !lurred

vision, drowsiness, and dry mouth. ymptoms o% e$trapyramidal e%%ects includetremors, restlessness, muscle spasms, and pseudopar/insonism.

4>. The nurse %ormulates a nursing diagnosis o% mpaired social interaction related todisorgani*ed thin/ing %or a client with schi*otypal personality disorder. &ased on thisnursing diagnosis, which nursing intervention ta/es highest priority

A. +elping the client to participate in social interactions

B. )stablishing a one-on-one relationship ith the client2. B$ploring the e%%ects o% the clients !ehavior on social interactions

D. Developing a schedule %or the clients participation in social interactions

Rationale# &y esta!lishing a one8on8one relationship, the nurse helps the client learnhow to interact with people in new situations. The other options are appropriate !ut

should ta/e place only a%ter the nurse8client relationship is esta!lished.

4@. A client with schi*ophrenia hears a voice telling him he is evil and must die. The

nurse understands that the client is e$periencing#

A. a delusion.&. %light o% ideas.

2. ideas o% re%erence.

. a hallucination.

Rationale# A hallucination is a sensory perception, such as hearing voices and seeingo!?ects, that only the client e$periences. A delusion is a %alse !elie%. light o% ideas

re%ers to a speech pattern in which the client s/ips %rom one unrelated su!?ect toanother. deas o% re%erence re%ers to the mista/en !elie% that someone or something

outside the client is controlling the clients ideas or !ehavior.

4. A client with delusional thin/ing shows a lac/ o% interest in eating at meal times.he states that she is unworthy o% eating and that her children will die i% she eats.

-hich nursing action would !e most appropriate %or this client

A. Telling the client that she may !ecome sic/ and die unless she eats&. Paying special attention to the clients rituals and emotions associated with meals

C. estricting the client(s access to food except at specified meal and snack


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timesD. Bncouraging the client to e$press her %eelings at meal times

Rationale# Restricting access to %ood e$cept at speci%ied times prevents the client

%rom eating when she %eels an$ious, guilty, or depressed9 this, in turn, decreases theassociation !etween these emotions and %ood. Telling the client she may !ecome sic/

or die may rein%orce her !ehavior !ecause illness or death may !e her goal. Payingspecial attention to rituals and emotions associated with meals also would rein%orceundesira!le !ehavior. Bncouraging the client to e$press %eelings at meal times would

increase the association !etween emotions and %ood9 instead, the nurse should

encourage her to e$press %eelings at other times.

4C. -hich o% the %ollowing groups o% characteristics would the nurse e$pect to see inthe client with schi*ophrenia

A. +oose associations0 grandiose delusions0 and auditory hallucinations

&. Periods o% hyperactivity and irrita!ility alternating with depression2. Delusions o% ?ealousy and persecution, paranoia, and mistrust

D. adness, apathy, %eelings o% worthlessness, anore$ia, and weight loss

Rationale# :oose associations, grandiose delusions, and auditory hallucinations areall characteristic o% the classic schi*ophrenic client. These clients arent a!le to care

%or their physical appearance. They %re'uently hear voices telling them to dosomething either to themselves or to others. Additionally, they ver!ally ram!le %rom

one topic to the ne$t. Periods o% hyperactivity and irrita!ility alternating withdepression are characteristic o% !ipolar or manic disease. Delusions o% ?ealousy and

persecution, paranoia, and mistrust are characteristics o% paranoid disorders.adness, apathy, %eelings o% worthlessness, anore$ia, and weight loss are

characteristics o% depression.

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akathisia.D. Administer an as needed dose o% haloperidol to decrease agitation.

Rationale# A/athisia, characteri*ed !y restlessness, is a common !ut o%ten

overloo/ed adverse reaction to haloperidol and other antipsychotic agents9 it may !econ%used with psychotic agitation. To control a/athisia, the nurse should give an as

needed dose o% a prescri!ed anticholinergic agent. The client cant control themovements, so as/ing him to sit still would !e pointless. As/ing him to leave theroom wouldnt address the underlying cause o% the pro!lem. Bncouraging him to tal/

a!out the symptoms wouldnt stop them %rom occurring. Hiving more antipsychotic

medication would worsen a/athisia.

;). A man is !rought to the hospital !y his wi%e, who states that %or the past wee/her hus!and has re%used all meals and accused her o% trying to poison him. During

the initial interview, the clients speech, only partly comprehensi!le, reveals that histhoughts are controlled !y delusions that he is possessed !y the devil. The physician

diagnoses paranoid schi*ophrenia. chi*ophrenia is !est descri!ed as a disordercharacteri*ed !y#

A. disturbed relationships related to an inability to communicate and thinkclearly.&. severe mood swings and periods o% low to high activity.

2. multiple personalities, one o% which is more destructive than the others.D. auditory and tactile hallucinations.

Rationale# chi*ophrenia is !est descri!ed as one o% a group o% psychotic reactions

characteri*ed !y distur!ed relationships with others and an ina!ility to communicateand thin/ clearly. chi*ophrenic thoughts, %eelings, and !ehavior commonly are

evidenced !y withdrawal, %luctuating moods, disordered thin/ing, and regressivetendencies. evere mood swings and periods o% low to high activity are typical o%

!ipolar disorder. (ultiple personality, sometimes con%used with schi*ophrenia, is a

dissociative personality disorder, not a psychotic illness. (any schi*ophrenic clientshave auditory hallucinations9 tactile hallucinations are more common in organic or

to$ic disorders

;4. A client has a history o% chronic undi%%erentiated schi*ophrenia. &ecause she hasa history o% noncompliance with antipsychotic therapy, shell receive %luphena*ine

decanoate 5Proli$in Decanoate6 in?ections every ; wee/s. &e%ore discharge, what

should the nurse include in her teaching plan

A. As/ing the physician %or droperidol 5napsine6 to control any e$trapyramidalsymptoms that occur

B. #itting up for a fe minutes before standing to minimi$e orthostatichypotension

2. 3oti%ying the physician i% her thoughts dont normali*e within 1 wee/D. B$pecting symptoms o% tardive dys/inesia to occur and to !e transient

Rationale# The nurse should teach the client how to manage common adverse

reactions, such as orthostatic hypotension and anticholinergic e%%ects. Antipsychotice%%ects o% the drug may ta/e several wee/s to appear. Droperidol increases the ris/

o% e$trapyramidal e%%ects when given in con?unction with phenothia*ines such as%luphena*ine. Tardive dys/inesia is a possi!le adverse reaction and should !e

reported immediately


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2. neologisms.D. nihilistic delusions.

Rationale# The correct answer is wa$y %le$i!ility, which is de%ined as retaining any

position that the !ody has !een placed in. omatic delusions involve a %alse !elie%a!out the %unctioning o% the !ody. 3eologisms are invented meaningless words.

3ihilistic delusions are %alse ideas a!out sel%, others, or the world.

;. A client with paranoid type schi*ophrenia !ecomes angry and tells the nurse to

leave him alone. The nurse should

A. tell him that she(ll leave for no but ill return soon.

&. as/ him i% its o/ay i% she sits 'uietly with him.2. as/ him why he wants to !e le%t alone.

D. tell him that she wont let anything happen to him

Rationale# % the client tells the nurse to leave, the nurse should leave !ut let theclient /now that shell return so that he doesnt %eel a!andoned. 3ot heeding the

clients re'uest can agitate him %urther. Also, challenging the client isnt therapeutic

and may increase his anger. alse reassurance isnt warranted in this situation

;C. 3ursing care %or a client with schi*ophrenia must !e !ased on valid psychiatric

and nursing theories. The nurses interpersonal communication with the client andspeci%ic nursing interventions must !e#

A. clearly identi%ied with !oundaries and speci%ically de%ined roles.

&. warm and nonthreatening.2. centered on clearly de%ined limits and e$pression o% empathy.

. flexible enough for the nurse to ad3ust the plan of care as the situationarrants.

Rationale# A %le$i!le plan o% care is needed %or any client who !ehaves in asuspicious, withdrawn, or regressed manner or who has a thought disorder. &ecause

such a client communicates at di%%erent levels and is in control o% himsel% at varioustimes, the nurse must !e a!le to ad?ust nursing care as the situation warrants. The

nurses role should !e clear9 however, the !oundaries or limits o% this role should !e%le$i!le enough to meet client needs. &ecause a client with schi*ophrenia %ears

closeness and a%%ection, a warm approach may !e too threatening. B$pressing

empathy is important, !ut centering interventions on clearly de%ined limits isimpossi!le !ecause the clients situation may change without warning.

=


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patency is compromised. :ecturing the client a!out !uying drugs on the street isntappropriate

=1. The nurse is caring %or a client with schi*ophrenia. -hich o% the %ollowing

outcomes is the least desira!le

A. 1he client spends more time by himself.&. The client doesnt engage in delusional thin/ing.2. The client doesnt harm himsel% or others.

D. The client demonstrates the a!ility to meet his own sel%8care needs.

Rationale# The client with schi*ophrenia is commonly socially isolated and

withdrawn9 there%ore, having the client spend more time !y himsel% wouldnt !e adesira!le outcome. Rather, a desira!le outcome would speci%y that the client spend

more time with other clients and sta%% on the unit. Delusions are %alse personal!elie%s. Reducing or eliminating delusional thin/ing using tal/ing therapy and

antipsychotic medications would !e a desira!le outcome. Protecting the client andothers %rom harm is a desira!le client outcome achieved !y close o!servation,

removing any dangerous o!?ects, and administering medications. &ecause the client

with schi*ophrenia may have di%%iculty meeting his or her own sel%8care needs,%ostering the a!ility to per%orm sel%8care independently is a desira!le client outcome.

=). The nurse %ormulates a nursing diagnosis o% mpaired ver!al communication %or aclient with schi*otypal personality disorder. &ased on this nursing diagnosis, which

nursing intervention is most appropriate

A. +elping the client to participate in social interactionsB. )stablishing a one-on-one relationship ith the client

2. Bsta!lishing alternative %orms o% communicationD. Allowing the client to decide when he wants to participate in ver!al

communication with the nurse

Rationale# &y esta!lishing a one8on8one relationship, the nurse helps the client learnhow to interact with people in new situations. The other options are appropriate !ut

should ta/e place only a%ter the nurse8client relationship is esta!lished.

=4. ince admission ; days ago, a client has re%used to ta/e a shower, stating,"There are poison crystals hidden in the showerhead. Theyll /ill me i% ta/e a

shower." -hich nursing action is most appropriate

A. Dismantling the showerhead and showing the client that there is nothing in it

&. B$plaining that other clients are complaining a!out the clients !ody odor2. As/ing a security o%%icer to assist in giving the client a shower

. Accepting these fears and alloing the client to take a sponge bath

Rationale# &y ac/nowledging the clients %ears, the nurse can arrange to meet theclients hygiene needs in another way. &ecause these %ears are real to the client,

providing a demonstration o% reality 5as in option A6 wouldnt !e e%%ective at thistime. 7ptions & and 2 would violate the clients rights !y shaming or em!arrassing

the client.

=;. Drug therapy with thiorida*ine 5(ellaril6 shouldnt e$ceed a daily dose o%


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A. +ypertension&. Respiratory arrest

2. Tourette syndrome. etinal pigmentation

Rationale# Retinal pigmentation may occur i% the thiorida*ine dosage e$ceeds . +ow soon a%ter chlorproma*ine 5Thora*ine6 administration should the nurse

e$pect to see a clients delusional thoughts and hallucinations eliminated

A. everal minutes&. everal hours

2. everal days

. #everal eeks

Rationale# Although most phenothia*ines produce some e%%ects within minutes tohours, their antipsychotic e%%ects may ta/e several wee/s to appear.

=@. A client is a!out to !e discharged with a prescription %or the antipsychotic agent

haloperidol 5+aldol6, 1< mg !y mouth twice per day. During a discharge teaching

session, the nurse should provide which instruction to the client

A. Ta/e the medication 1 hour !e%ore a meal.&. Decrease the dosage i% signs o% illness decrease.

C. Apply a sunscreen before being exposed to the sun.D. ncrease the dosage up to =< mg twice per day i% signs o% illness dont decrease.

Rationale# &ecause haloperidol can cause photosensitivity and precipitate severe

sun!urn, the nurse should instruct the client to apply a sunscreen !e%ore e$posure tothe sun. The nurse also should teach the client to ta/e haloperidol with meals K not

1 hour !e%ore K and should instruct the client not to decrease or increase the dosageunless the physician orders it

=. A client with paranoid schi*ophrenia repeatedly uses pro%anity during an activity

therapy session. -hich response !y the nurse would !e most appropriate


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A. "Your behavior on(t be tolerated. *o to your room immediately."

&. "Youre ?ust doing this to get !ac/ at me %or ma/ing you come to therapy."2. "Your cursing is interrupting the activity. Ta/e time out in your room %or 1

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