Questions and Rationale on Psychotic Disorders 1.

A psychotic client reports to the evening nurse that the day nurse put something suspicious in his water with his medication. The nurse replies, "You re worried a!out your medication"" The nurse s communication is# A. an e$ample o% presenting reality. &. rein%orcing the client s delusions. C. focusing on emotional content. D. a nontherapeutic techni'ue called mind reading. Rationale# The nurse should help the client %ocus on the emotional content rather than delusional material. Presenting reality isn t help%ul !ecause it can lead to con%rontation and disengagement. Agreeing with the client and supporting his !elie%s are rein%orcing delusions. (ind reading isn t therapeutic. ). A client is admitted to the inpatient unit o% the mental health center with a diagnosis o% paranoid schi*ophrenia. +e s shouting that the government o% ,rance is trying to assassinate him. -hich o% the %ollowing responses is most appropriate" A. ". thin/ you re wrong. ,rance is a %riendly country and an ally o% the 0nited 1tates. Their government wouldn t try to /ill you." B. "I find it hard to believe that a foreign government or anyone else is trying to hurt you. You must feel frightened by this." 2. "You re wrong. 3o!ody is trying to /ill you." D. "A %oreign government is trying to /ill you" Please tell me more a!out it." Rationale# Responses should %ocus on reality while ac/nowledging the client s %eelings. Arguing with the client or denying his !elie% isn t therapeutic. Arguing can also inhi!it development o% a trusting relationship. 2ontinuing to tal/ a!out delusions may aggravate the psychosis. As/ing the client i% a %oreign government is trying to /ill him may increase his an$iety level and can rein%orce his delusions. 4. Propranolol 5.nderal6 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*ophrenia D. 7!sessive8compulsive disorder 572D6 to reduce ritualistic !ehavior Rationale# Propranolol is a potent !eta8adrenergic !loc/er and produces a sedating e%%ect9 there%ore, it s used to treat antipsychotic induced a/athisia and an$iety. :ithium 5:itho!id6 is used to sta!ili*e clients with !ipolar illness. Antipsychotics are used to treat delusions. 1ome antidepressants have !een e%%ective in treating 72D. ;. A client with !orderline personality disorder !ecomes angry when he is told that today s psychotherapy session with the nurse will !e delayed 4< minutes !ecause o% an emergency. -hen the session %inally !egins, the client e$presses anger. -hich response !y the nurse would !e most help%ul in dealing with the client s anger" A. ".% it had !een your emergency, . would have made the other client wait." &. ". /now it s %rustrating to wait. . m sorry this happened."

C. "You had to ait. Can e talk about ho this is making you feel right no !" D. ". really care a!out you and . ll never let this happen again." Rationale# This response may di%%use the client s anger !y helping to maintain a therapeutic relationship and addressing the client s %eelings. 7ption A wouldn t address the client s anger. 7ption & is incorrect !ecause the client with a !orderline personality disorder !lames others %or things that happen, so apologi*ing rein%orces the client s misconceptions. The nurse can t promise that a delay will never occur again, as in option D, !ecause such matters are outside the nurse s control. =. +ow soon a%ter chlorproma*ine 5Thora*ine6 administration should the nurse e$pect to see a client s delusional thoughts and hallucinations eliminated A. 1everal minutes &. 1everal hours 2. 1everal days ". #everal eeks Rationale# Although most phenothia*ines produce some e%%ects within minutes to hours, their antipsychotic e%%ects may ta/e several wee/s to appear. >. A client receiving haloperidol 5+aldol6 complains o% a sti%% ?aw and di%%iculty swallowing. The nurse s %irst action is to# A. reassure the client and administer as needed lora*epam 5Ativan6 ..(. B. administer as needed dose of ben$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$trapyramidal e%%ects. Another dose o% haloperidol would increase the severity o% the reaction. @. A client with a diagnosis o% paranoid schi*ophrenia comments to the nurse, "+ow do . /now what is really in those pills"" -hich o% the %ollowing is the !est response" A. 1ay, "You /now it s your medicine." B. Allo him to open the individual rappers of the medication. 2. 1ay, "Don t worry a!out what is in the pills. .t s what is ordered." D. .gnore the comment !ecause it s pro!a!ly a ?o/e. Rationale# 7ption & is correct !ecause allowing a paranoid client to open his medication can help reduce suspiciousness. 7ption A is incorrect !ecause the client doesn t /now that it s his medication and he s o!viously suspicious. Telling the client not to worry or ignoring the comment isn t supportive and doesn t o%%er reassurance. A. The nurse is caring %or a client with schi*ophrenia who e$periences auditory hallucinations. The client appears to !e listening to someone who isn t visi!le. +e gestures, shouts angrily, and stops shouting in mid8sentence. -hich nursing intervention is the most appropriate"

A. Approach the client and touch him to get his attention. &. Bncourage the client to go to his room where he ll e$perience %ewer distractions. C. Ackno ledge that the client is hearing voices but make it clear that the nurse doesn(t hear these voices. D. As/ the client to descri!e what the voices are saying. Rationale# &y ac/nowledging that the client hears voices, the nurse conveys acceptance o% the client. &y letting the client /now that the nurse doesn t hear the voices, the nurse avoids rein%orcing the hallucination. The nurse shouldn t touch the client with schi*ophrenia without advance warning. The hallucinating client may !elieve that the touch is a threat or act o% aggression and respond violently. &eing alone in his room encourages the client to withdraw and may promote more hallucinations. The nurse should provide an activity to distract the client. &y as/ing the client what the voices are saying, the nurse is rein%orcing the hallucination. The nurse should %ocus on the client s %eelings, rather than the content o% the hallucination. C. Yesterday, a client with schi*ophrenia !egan treatment with haloperidol 5+aldol6. Today, the nurse notices that the client is holding his head to one side and complaining o% nec/ and ?aw spasms. -hat should the nurse do" A. Assume that the client is posturing. &. Tell the client to lie down and rela$. C. )valuate the client for adverse reactions to haloperidol. D. Put the client on the list %or the physician to see tomorrow Rationale# An antipsychotic agent, such as haloperidol, can cause muscle spasms in the nec/, %ace, tongue, !ac/, and sometimes legs as well as torticollis 5twisted nec/ position6. The nurse should !e aware o% these adverse reactions and assess %or related reactions promptly. Although posturing may occur in clients with schi*ophrenia, it isn t the same as nec/ and ?aw spasms. +aving the client rela$ can reduce tension8induced muscle sti%%ness !ut not drug8induced muscle spasms. -hen a client develops a new sign or symptom, the nurse should consider an adverse drug reaction as the possi!le cause and o!tain treatment immediately, rather than have the client wait. 1<. A client with paranoid schi*ophrenia has !een e$periencing auditory hallucinations %or many years. 7ne approach that has proven to !e e%%ective %or hallucinating clients is to# A. ta/e an as8needed dose o% psychotropic medication whenever they hear voices. B. practice saying "*o a ay" or "#top" hen they hear voices. 2. sing loudly to drown out the voices and provide a distraction. D. go to their room until the voices go away. Rationale# Researchers have %ound that some clients can learn to control !othersome hallucinations !y telling the voices to go away or stop. Ta/ing an as needed dose o% psychotropic medication whenever the voices arise may lead to overmedication and put the client at ris/ %or adverse e%%ects. &ecause the voices aren t li/ely to go away permanently, the client must learn to deal with the hallucinations without relying on drugs. Although distraction is help%ul, singing loudly may upset other clients and would !e socially unaccepta!le a%ter the client is discharged. +allucinations are most !othersome in a 'uiet environment when the client is alone, so sending the client to

his room would increase, rather than decrease, the hallucinations. 11. A client with catatonic schi*ophrenia is mute, can t per%orm activities o% daily living, and stares out the window %or hours. -hat is the nurse s %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 (aslow s hierarchy o% needs, the need %or %ood is among the most 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 secret message to her. The nurse suspects the client is e$periencing# A. a delusion. &. %light o% ideas. C. ideas of reference. D. a hallucination. Rationale# .deas o% re%erence re%ers to the mista/en !elie% that neutral stimuli have special meaning to the individual such as the television newscaster sending a message directly to the individual. A delusion is a %alse !elie%. ,light o% ideas is a speech pattern in which the client s/ips %rom one unrelated su!?ect to another. A hallucination is a sensory perception, such as hearing voices and seeing o!?ects, that only the client e$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 A years can t complete activities o% daily living 5AD:s6 without sta%% direction and assistance. The nurse %ormulates a nursing diagnosis o% 1el%8care de%icient# DressingDgrooming 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."

Rationale# The client s disorgani*ed personality and history o% hospitali*ation have a%%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 can provide needed structure !y helping the client select grooming items and clothing. This goal promotes realistic independence. As the client improves and achieves the esta!lished goal, the nurse can set new goals that %ocus on the client completing AD:s with only ver!al encouragement and, ultimately, completing them independently. The client s condition doesn t 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 a diagnosis o% paranoid schi*ophrenia. -hich nursing diagnosis should receive the highest priority" A. -isk for violence to ard self or others &. .m!alanced nutrition# :ess than !ody re'uirements 2. .ne%%ective %amily coping D. .mpaired ver!al communication Rationale# &ecause o% such %actors as suspiciousness, an$iety, and hallucinations, the client with paranoid schi*ophrenia is at ris/ %or violence toward himsel% or others. The other options are also appropriate nursing diagnoses !ut should !e addressed a%ter the sa%ety o% the client and those around him is esta!lished. 1>. The nurse is preparing %or the discharge o% a client who has !een hospitali*ed %or paranoid schi*ophrenia. The client s hus!and e$presses concern over whether his wi%e will continue to ta/e her daily prescri!ed medication. The nurse should in%orm him 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%e s %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 the client receives the in?ection at the outpatient clinic. A client has the right to re%use medication, !ut this issue isn t the %ocus o% discussion at this time. (edication should never !e hidden in %ood or drin/ to tric/ the client into ta/ing it9 !esides destroying the client s trust, doing so would place the client at ris/ %or overmedication or undermedication !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 231.

D. increasing norepinephrine in the 231. Rationale# 7ption & is the action o% 2ogentin. An$iety doesn t cause e$trapyramidal e%%ects. 7veractivity o% acetylcholine and lower levels o% dopamine are the causes o% e$trapyramidal e%%ects. &en*tropine doesn t increase norepinephrine in the 231. 1A. A client is admitted to the inpatient unit o% the mental health center with a diagnosis o% paranoid schi*ophrenia. +e s shouting that the government o% ,rance is trying to assassinate him. -hich o% the %ollowing responses is most appropriate" A. ". thin/ you re wrong. ,rance is a %riendly country and an ally o% the 0nited 1tates. Their government wouldn t try to /ill you." B. "I find it hard to believe that a foreign government or anyone else is trying to hurt you. You must feel frightened by this." 2. "You re wrong. 3o!ody is trying to /ill you." D. "A %oreign government is trying to /ill you" Please tell me more a!out it." Rationale# Responses should %ocus on reality while ac/nowledging the client s %eelings. Arguing with the client or denying his !elie% isn t therapeutic. Arguing can also inhi!it development o% a trusting relationship. 2ontinuing to tal/ a!out delusions may aggravate the psychosis. As/ing the client i% a %oreign government is trying to /ill him may increase his an$iety level and can rein%orce his delusions. 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 52316. &. !loc/ing acetylcholine in the 231. 2. activating norepinephrine in the 231. ". activating dopamine receptors in the C/#. Rationale# B$trapyramidal e%%ects and the muscle rigidity induced !y antipsychotic medications are caused !y a low level o% dopamine. Dopamine receptor agonists stimulate dopamine receptors and there!y reduce rigidity. They don t a%%ect norepinephrine or acetylcholine. )<. (ost antipsychotic medications e$ert which o% %ollowing e%%ects on the central nervous system 52316" A. 1timulate the 231 !y !loc/ing postsynaptic dopamine, norepinephrine, and serotonin receptors. &. 1edate the 231 !y stimulating serotonin at the synaptic cle%t. C. "epress the C/# by blocking the postsynaptic transmission of dopamine0 serotonin0 and norepinephrine. D. Depress the 231 !y stimulating the release o% acetylcholine. Rationale# The e$act mechanism o% antipsychotic medication action is un/nown, !ut appear to depress the 231 !y !loc/ing the transmission o% three neurotransmitters# dopamine, serotonin, and norepinephrine. They don t sedate the 231 !y stimulating serotonin, and they don t stimulate neurotransmitter action or acetylcholine release. )1. A client is admitted to the psychiatric unit o% a local hospital with chronic undi%%erentiated schi*ophrenia. During the ne$t several days, the client is seen

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$ternal stimuli e$ist, is common in schi*ophrenic clients. 1uch !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$ternal stimuli. 2lients with schi*ophrenia may e$hi!it looseness o% association, a pattern o% thin/ing and communicating in which ideas aren t clearly lin/ed to one another. .llusion is a less severe 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 order to reverse a dystonic reaction" A. prochlorpera*ine 52ompa*ine6 B. diphenhydramine %Benadryl& 2. haloperidol 5+aldol6 D. mida*olam 5Eersed6 Rationale# Diphenhydramine, )= to =< mg ..(. or ..E., would 'uic/ly reverse this condition. 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 !y the nurse would !e most therapeutic" A. "I don(t hear the voice0 but I kno you hear hat sounds like a voice." &. "You shouldn t %ocus on that voice." 2. "Don t worry a!out the voice as long as it doesn t !elong to anyone real." D. "Fing Tut has !een dead %or years." Rationale# This response states reality a!out the client s 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, "You re worried a!out your medication"" The nurse s communication is# A. an e$ample o% presenting reality. &. rein%orcing the client s 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 isn t help%ul !ecause it can lead to con%rontation and disengagement. Agreeing with the client and supporting his !elie%s are rein%orcing delusions. (ind reading isn t therapeutic.

)=. The nurse is caring %or a client with schi*ophrenia who e$periences auditory hallucinations. The client appears to !e listening to someone who isn t visi!le. +e gestures, shouts angrily, and stops shouting in mid8sentence. -hich nursing intervention is the most appropriate" A. Approach the client and touch him to get his attention. &. Bncourage the client to go to his room where he ll e$perience %ewer distractions. C. Ackno ledge that the client is hearing voices but make it clear that the nurse 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 doesn t hear the voices, the nurse avoids rein%orcing the hallucination. The nurse shouldn t 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 more hallucinations. 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 client s %eelings, rather than the content o% the hallucination. )>. A client has !een receiving chlorproma*ine 5Thora*ine6, an antipsychotic, to treat his psychosis. -hich %indings should alert the nurse that the client is e$periencing pseudopar/insonism" A. Restlessness, di%%iculty sitting still, and pacing &. .nvoluntary rolling o% the eyes C. 1remors0 shuffling gait0 and masklike face D. B$tremity and nec/ spasms, %acial grimacing, and ?er/y movements Rationale# Pseudopar/insonism may appear 1 to = days a%ter starting an antipsychotic 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 !e considered 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<)G , 54A.CG 26, a heart rate o% 1)< !eatsDminute, a respiratory rate o% )< !reathsDminute, and a !lood pressure o% )1<D1;< mm +g. &ecause the client also is con%used and incontinent, the nurse suspects malignant neuroleptic syndrome. -hat steps should the nurse ta/e" A. Hive the ne$t dose o% %luphena*ine, call the physician, and monitor vital signs. B. 2ithhold the next dose of fluphena$ine0 call the physician0 and monitor vital signs. 2. Hive the ne$t dose o% %luphena*ine and restrict the client to the room to decrease stimulation. D. -ithhold the ne$t dose o% %luphena*ine, administer an antipyretic agent, and

increase the client s %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$t dose, noti%y the physician, and continue to monitor vital signs. Although an antipyretic agent may !e used to reduce %ever, increased %luid inta/e is contraindicated !ecause it may increase the client s %luid volume %urther, raising !lood pressure even higher. )A. A schi*ophrenic client with delusions tells the nurse, "There is a man wearing a red coat who s out to get me." The client e$hi!its increasing an$iety when %ocusing on the delusions. -hich o% the %ollowing would !e the !est response" A. "1his sub3ect seems to be troubling you. +et(s alk to the activity room." &. "Descri!e the man who s out to get you. -hat does he loo/ li/e"" 2. "There is no reason to !e a%raid o% that man. This hospital is very secure." D. "There is no need to !e concerned with a man who isn t even real." Rationale# This remar/ distracts the client %rom the delusion !y engaging the client in a less threatening or more com%orting activity at the %irst sign o% an$iety. The nurse should rein%orce reality and discourage the %alse !elie%. The other options %ocus on the content o% the delusion rather than the meaning, %eeling, or intent that it provo/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 amenorrhea D. .nstruction that amenorrhea is irreversi!le Rationale# -omen may e$perience amenorrhea, which is reversi!le, while ta/ing antipsychotics. Amenorrhea doesn t indicate cessation o% ovulation9 there%ore, the client can still !ecome pregnant. The client should !e instructed to continue contraceptive use even when e$periencing amenorrhea. Dysmenorrhea isn t an adverse e%%ect o% antipsychotics, and li!ido generally decreases !ecause o% the depressant e%%ect. 4<. A client is admitted to a psychiatric %acility with a diagnosis o% chronic schi*ophrenia. The history indicates that the client has !een ta/ing neuroleptic medication %or many years. Assessment reveals unusual movements o% the tongue, nec/, and arms. -hich condition should the nurse suspect" A. 1ardive dyskinesia &. Dystonia 2. 3euroleptic malignant syndrome D. A/athisia Rationale# 0nusual movements o% the tongue, nec/, and arms suggest tardive dys/inesia, an adverse reaction to neuroleptic medication. Dystonia is characteri*ed !y cramps and rigidity o% the tongue, %ace, nec/, and !ac/ muscles. 3euroleptic malignant syndrome causes rigidity, %ever, hypertension, and diaphoresis. A/athisia causes restlessness, an$iety, and ?itteriness.

41. -hat medication would pro!a!ly !e ordered %or the acutely aggressive schi*ophrenic client" A. chlorproma*ine 5Thora*ine6 B. haloperidol %4aldol& 2. lithium car!onate 5:ithonate6 D. amitriptyline 5Blavil6 Rationale# +aloperidol administered ..(. or ..E. is the drug o% choice %or acute aggressive psychotic !ehavior. 2hlorproma*ine is also an antipsychotic drug9 however, 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. -hich signs would this client e$hi!it during social situations" A. Aggressive !ehavior B. 5aranoid thoughts 2. Bmotional a%%ect D. .ndependence needs Rationale# 2lients with schi*otypal personality disorder e$perience e$cessive social an$iety that can lead to paranoid thoughts. Aggressive !ehavior is uncommon, although these clients may e$perience agitation with an$iety. Their !ehavior is emotionally 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 the empty chair !eside him and whispers, "3ow ?ust leave. . told you to stay home. There isn t enough wor/ here %or !oth o% usI" -hat is the nurse s !est initial response" A. "2hen people are under stress0 they may see things or hear things that others 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 to loo/ at the nurse wouldn t address the o!vious issue o% the hallucination. 2on%rontational approaches, such as in options 2 and D, are li/ely to elicit an unin%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.

1omatic delusions involve a %alse !elie% a!out the %unctioning o% the !ody. &ody dysmorphic disorder is characteri*ed !y a !elie% that the !ody is de%ormed or de%ective in a speci%ic way. Apra$ia is the ina!ility to carry out motor activities. 4=. A client who s ta/ing antipsychotic medication develops a very high temperature, severe muscle rigidity, tachycardia, and rapid deterioration in mental status. The nurse suspects what complication o% antipsychotic therapy" A. Agranulocytosis &. B$trapyramidal e%%ects 2. Anticholinergic e%%ects ". /euroleptic malignant syndrome %/'#& Rationale# A rare !ut potentially %atal condition o% antipsychotic medication is called 3(1. .t generally starts with an elevated temperature and severe e$trapyramidal e%%ects. Agranulocytosis is a !lood disorder. Anticholinergic e%%ects include !lurred vision, drowsiness, and dry mouth. 1ymptoms o% e$trapyramidal e%%ects include tremors, restlessness, muscle spasms, and pseudopar/insonism. 4>. The nurse %ormulates a nursing diagnosis o% .mpaired social interaction related to disorgani*ed thin/ing %or a client with schi*otypal personality disorder. &ased on this nursing 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 client 2. B$ploring the e%%ects o% the client s !ehavior on social interactions D. Developing a schedule %or the client s participation in social interactions Rationale# &y esta!lishing a one8on8one relationship, the nurse helps the client learn how to interact with people in new situations. The other options are appropriate !ut should ta/e place only a%ter the nurse8client relationship is esta!lished. 4@. A client with schi*ophrenia hears a voice telling him he is evil and must die. The nurse understands that the client is e$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 seeing o!?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 to another. .deas o% re%erence re%ers to the mista/en !elie% that someone or something outside the client is controlling the client s ideas or !ehavior. 4A. A client with delusional thin/ing shows a lac/ o% interest in eating at meal times. 1he 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 client s rituals and emotions associated with meals C. -estricting the client(s access to food except at specified meal and snack

times D. 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$ious, guilty, or depressed9 this, in turn, decreases the association !etween these emotions and %ood. Telling the client she may !ecome sic/ or die may rein%orce her !ehavior !ecause illness or death may !e her goal. Paying special attention to rituals and emotions associated with meals also would rein%orce undesira!le !ehavior. Bncouraging the client to e$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 in the client with schi*ophrenia" A. +oose associations0 grandiose delusions0 and auditory hallucinations &. Periods o% hyperactivity and irrita!ility alternating with depression 2. Delusions o% ?ealousy and persecution, paranoia, and mistrust D. 1adness, apathy, %eelings o% worthlessness, anore$ia, and weight loss Rationale# :oose associations, grandiose delusions, and auditory hallucinations are all characteristic o% the classic schi*ophrenic client. These clients aren t a!le to care %or their physical appearance. They %re'uently hear voices telling them to do something either to themselves or to others. Additionally, they ver!ally ram!le %rom one topic to the ne$t. Periods o% hyperactivity and irrita!ility alternating with depression are characteristic o% !ipolar or manic disease. Delusions o% ?ealousy and persecution, paranoia, and mistrust are characteristics o% paranoid disorders. 1adness, apathy, %eelings o% worthlessness, anore$ia, and weight loss are characteristics o% depression. ;<. The nurse must administer a medication to reverse or prevent Par/inson8type symptoms in a client receiving an antipsychotic. The medication the client will li/ely receive is# A. Ben$tropine %Cogentin&. &. diphenhydramine 5&enadryl6. 2. propranolol 5.nderal6. D. haloperidol 5+aldol6. Rationale# &en*tropine, trihe$yphenidyl, or amantadine are prescri!ed %or a client with Par/inson8type symptoms. Diphenhydramine provides rapid relie% %or dystonia. Propranolol relieves a/athisia. +aloperidol can cause Par/inson8type symptoms. ;1. A client is receiving haloperidol 5+aldol6 to reduce psychotic symptoms. As he watches television with other clients, the nurse notes that he has trou!le sitting still. +e seems restless, constantly moving his hands and %eet and changing position. -hen the nurse as/s what is wrong, he says he %eels ?ittery. +ow should the nurse manage this situation" A. As/ the client to sit still or leave the room !ecause he is distracting the other clients. &. As/ the client i% he is nervous or an$ious a!out something. C. *ive an as needed dose of a prescribed anticholinergic agent to control

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 !e con%used with psychotic agitation. To control a/athisia, the nurse should give an as needed dose o% a prescri!ed anticholinergic agent. The client can t control the movements, so as/ing him to sit still would !e pointless. As/ing him to leave the room wouldn t address the underlying cause o% the pro!lem. Bncouraging him to tal/ a!out the symptoms wouldn t 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 client s speech, only partly comprehensi!le, reveals that his thoughts are controlled !y delusions that he is possessed !y the devil. The physician diagnoses paranoid schi*ophrenia. 1chi*ophrenia is !est descri!ed as a disorder characteri*ed !y# A. disturbed relationships related to an inability to communicate and think clearly. &. 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# 1chi*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 communicate and thin/ clearly. 1chi*ophrenic thoughts, %eelings, and !ehavior commonly are evidenced !y withdrawal, %luctuating moods, disordered thin/ing, and regressive tendencies. 1evere 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 clients have auditory hallucinations9 tactile hallucinations are more common in organic or to$ic disorders ;4. A client has a history o% chronic undi%%erentiated schi*ophrenia. &ecause she has a history o% noncompliance with antipsychotic therapy, she ll receive %luphena*ine decanoate 5Proli$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 5.napsine6 to control any e$trapyramidal symptoms that occur B. #itting up for a fe minutes before standing to minimi$e orthostatic hypotension 2. 3oti%ying the physician i% her thoughts don t normali*e within 1 wee/ D. B$pecting symptoms o% tardive dys/inesia to occur and to !e transient Rationale# The nurse should teach the client how to manage common adverse reactions, such as orthostatic hypotension and anticholinergic e%%ects. Antipsychotic e%%ects o% the drug may ta/e several wee/s to appear. Droperidol increases the ris/ o% e$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

;;. A client with chronic schi*ophrenia who ta/es neuroleptic medication is admitted to the psychiatric unit. 3ursing assessment reveals rigidity, %ever, hypertension, and diaphoresis. These %indings suggest which li%e8threatening reaction# A. tardive dys/inesia. &. dystonia. C. neuroleptic malignant syndrome. D. a/athisia. Rationale# The client s signs and symptoms suggest neuroleptic malignant syndrome, a li%e8threatening reaction to neuroleptic medication that re'uires immediate treatment. Tardive dys/inesia causes involuntary movements o% the tongue, mouth, %acial muscles, and arm and leg muscles. Dystonia is characteri*ed !y cramps and rigidity o% the tongue, %ace, nec/, and !ac/ muscles. A/athisia causes restlessness, an$iety, and ?itteriness. ;=. -hile loo/ing out the window, a client with schi*ophrenia remar/s, "That school across the street has creatures in it that are waiting %or me." -hich o% the %ollowing terms !est descri!es what the creatures represent" A. An$iety attac/ &. Pro?ection 2. +allucination ". "elusion Rationale# A delusion is a %alse !elie% !ased on a misrepresentation o% a real event or e$perience. Although an$iety can increase delusional responses, it isn t considered the primary symptom. Pro?ection is %alsely attri!uting to another person one s own unaccepta!le %eelings. +allucinations, which characteri*e most psychoses, are perceptual disorders o% the %ive senses9 the client may see, taste, %eel, smell, or hear something in the a!sence o% e$ternal stimulation ;>. A client with schi*ophrenia tells the nurse, "(y intestines are rotted %rom the worms chewing on them." This statement indicates a# A. delusion o% persecution. &. delusion o% grandeur. C. somatic delusion. D. ?ealous delusion. Rationale# 1omatic delusions %ocus on !odily %unctions or systems and commonly include delusions a!out %oul odor emissions, insect in%estations, internal parasites, and misshapen parts. Delusions o% persecution are mor!id !elie%s that one is !eing mistreated and harassed !y unidenti%ied enemies. Delusions o% grandeur are gross e$aggerations o% one s importance, wealth, power, or talents. Jealous delusions are delusions that one s spouse or lover is un%aith%ul. ;@. During the assessment stage, a client with schi*ophrenia leaves his arm in the air a%ter the nurse has ta/en his !lood pressure. +is action shows evidence o%# A. somatic delusions. B. axy flexibility.

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. 1omatic 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. 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% it s o/ay i% she sits 'uietly with him. 2. as/ him why he wants to !e le%t alone. D. tell him that she won t let anything happen to him Rationale# .% the client tells the nurse to leave, the nurse should leave !ut let the client /now that she ll return so that he doesn t %eel a!andoned. 3ot heeding the client s re'uest can agitate him %urther. Also, challenging the client isn t therapeutic and may increase his anger. ,alse reassurance isn t warranted in this situation ;C. 3ursing care %or a client with schi*ophrenia must !e !ased on valid psychiatric and nursing theories. The nurse s interpersonal communication with the client and speci%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$pression o% empathy. ". flexible enough for the nurse to ad3ust the plan of care as the situation arrants. Rationale# A %le$i!le plan o% care is needed %or any client who !ehaves in a suspicious, 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 various times, the nurse must !e a!le to ad?ust nursing care as the situation warrants. The nurse s 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 is impossi!le !ecause the client s situation may change without warning. =<. -hen discharging a client a%ter treatment %or a dystonic reaction, the emergency department nurse must ensure that the client understands which o% the %ollowing" A. Results o% treatment are rapid and dramatic !ut may not last. &. Although uncom%orta!le, this reaction isn t serious. 2. The client shouldn t !uy drugs on the street. ". 1he client must take ben$tropine %Cogentin& as prescribed to prevent a return of symptoms. Rationale# An oral anticholinergic agent such as !en*tropine 52ogentin6 is commonly prescri!ed to control and prevent the return o% symptoms. Dystonic reactions are typically acute and reversi!le. Dystonic reactions can !e li%e8threatening when airway

patency is compromised. :ecturing the client a!out !uying drugs on the street isn t appropriate =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 doesn t engage in delusional thin/ing. 2. The client doesn t 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% wouldn t !e a desira!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 and others %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 a client with schi*otypal personality disorder. &ased on this nursing diagnosis, which nursing intervention is most appropriate" A. +elping the client to participate in social interactions B. )stablishing a one-on-one relationship ith the client 2. Bsta!lishing alternative %orms o% communication D. 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 learn how 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. 1ince admission ; days ago, a client has re%used to ta/e a shower, stating, "There are poison crystals hidden in the showerhead. They ll /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$plaining that other clients are complaining a!out the client s !ody odor 2. As/ing a security o%%icer to assist in giving the client a shower ". Accepting these fears and allo ing the client to take a sponge bath Rationale# &y ac/nowledging the client s %ears, the nurse can arrange to meet the client s hygiene needs in another way. &ecause these %ears are real to the client, providing a demonstration o% reality 5as in option A6 wouldn t !e e%%ective at this time. 7ptions & and 2 would violate the client s rights !y shaming or em!arrassing the client. =;. Drug therapy with thiorida*ine 5(ellaril6 shouldn t e$ceed a daily dose o% A<< mg to prevent which adverse reaction"

A. +ypertension &. Respiratory arrest 2. Tourette syndrome ". -etinal pigmentation Rationale# Retinal pigmentation may occur i% the thiorida*ine dosage e$ceeds A<< mg per day. The other options don t occur as a result o% e$ceeding this dose. ==. A client with paranoid personality disorder is admitted to a psychiatric %acility. -hich remar/ !y the nurse would !est esta!lish rapport and encourage the client to con%ide in the nurse" A. "I get upset once in a hile0 too." &. ". /now ?ust how you %eel. . d %eel the same way in your situation." 2. ". worry, too, when . thin/ people are tal/ing a!out me." D. "At times, it s normal not to trust anyone." Rationale# 1haring a !enign, nonthreatening, personal %act or %eeling helps the nurse esta!lish rapport and encourages the client to con%ide in the nurse. The nurse can t /now how the client %eels. Telling the client otherwise, as in option &, would ?usti%y the suspicions o% a paranoid client9 %urthermore, the client relies on the nurse to interpret reality. 7ption 2 is incorrect !ecause it %ocuses on the nurse s %eelings, not the client s. 7ption D wouldn t help esta!lish rapport or encourage the client to con%ide in the nurse =>. +ow soon a%ter chlorproma*ine 5Thora*ine6 administration should the nurse e$pect to see a client s delusional thoughts and hallucinations eliminated" A. 1everal minutes &. 1everal hours 2. 1everal days ". #everal eeks Rationale# Although most phenothia*ines produce some e%%ects within minutes to hours, their antipsychotic e%%ects may ta/e several wee/s to appear. =@. A client is a!out to !e discharged with a prescription %or the antipsychotic agent haloperidol 5+aldol6, 1< mg !y mouth twice per day. During a discharge teaching session, the nurse should provide which instruction to the client" A. Ta/e the medication 1 hour !e%ore a meal. &. Decrease the dosage i% signs o% illness decrease. C. Apply a sunscreen before being exposed to the sun. D. .ncrease the dosage up to =< mg twice per day i% signs o% illness don t decrease. Rationale# &ecause haloperidol can cause photosensitivity and precipitate severe sun!urn, the nurse should instruct the client to apply a sunscreen !e%ore e$posure to the 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 dosage unless the physician orders it =A. A client with paranoid schi*ophrenia repeatedly uses pro%anity during an activity therapy session. -hich response !y the nurse would !e most appropriate"

A. "Your behavior on(t be tolerated. *o to your room immediately." &. "You re ?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< minutes." D. ". m disappointed in you. You can t control yoursel% even %or a %ew minutes." Rationale# The nurse should set limits on client !ehavior to ensure a com%orta!le environment %or all clients. The nurse should accept hostile or 'uarrelsome client out!ursts within limits without !ecoming personally o%%ended, as in option A. 7ption & is incorrect !ecause it implies that the client s actions re%lect %eelings toward the sta%% instead o% the client s own misery. Judgmental remar/s, such as option D, may decrease the client s sel%8esteem. =C. -hich o% the %ollowing is one o% the advantages o% the newer antipsychotic medication risperidone 5Risperdal6" A. The a!sence o% anticholinergic e%%ects B. A lo er incidence of extrapyramidal effects 2. Photosensitivity and sedation D. 3o incidence o% neuroleptic malignant syndrome Rationale# Risperdal has a lower incidence o% e$trapyramidal e%%ects than the typical antipsychotics. Risperdal does produce anticholinergic e%%ects and neuroleptic malignant syndrome can occur. Photosensitivity isn t an advantage. ><. The etiology o% schi*ophrenia is !est descri!ed !y# A. genetics due to a %aulty dopamine receptor. &. environmental %actors and poor parenting. 2. structural and neuro!iological %actors. ". a combination of biological0 psychological0 and environmental factors. Rationale# A relia!le genetic mar/er hasn t !een determined %or schi*ophrenia. +owever, studies o% twins and adopted si!lings have strongly implicated a genetic predisposition. 1ince the mid81Cth century, e$cessive dopamine activity in the !rain has also !een suggested as a causal %actor. 2ommunication and the %amily system have !een studied as contri!uting %actors in the development o% schi*ophrenia. There%ore, a com!ination o% !iological, psychological, and environmental %actors are thought to cause schi*ophrenia. >1. A client with schi*ophrenia who receives %luphena*ine 5Proli$in6 develops pseudopar/insonism and a/inesia. -hat drug would the nurse administer to minimi*e e$trapyramidal symptoms" A. ben$tropine %Cogentin& &. dantrolene 5Dantrium6 2. clona*epam 5Flonopin6 D. dia*epam 5Ealium6 Rationale# &en*tropine is an anticholinergic drug administered to reduce e$trapyramidal adverse e%%ects in the client ta/ing antipsychotic drugs. .t wor/s !y restoring the e'uili!rium !etween the neurotransmitters acetylcholine and dopamine

in the central nervous system 52316. Dantrolene, a hydantoin drug that reduces the cata!olic processes, is administered to alleviate the symptoms o% neuroleptic malignant syndrome, a potentially %atal adverse e%%ect o% antipsychotic drugs. 2lona*epam, a !en*odia*epine drug that depresses the 231, is administered to control sei*ure activity. Dia*epam, a !en*odia*epine drug, is administered to reduce an$iety. >). A client with a diagnosis o% paranoid schi*ophrenia comments to the nurse, "+ow do . /now what is really in those pills"" -hich o% the %ollowing is the !est response" A. 1ay, "You /now it s your medicine." B. Allo him to open the individual rappers of the medication. 2. 1ay, "Don t worry a!out what is in the pills. .t s what is ordered." D. .gnore the comment !ecause it s pro!a!ly a ?o/e. Rationale# 7ption & is correct !ecause allowing a paranoid client to open his medication can help reduce suspiciousness. 7ption A is incorrect !ecause the client doesn t /now that it s his medication and he s o!viously suspicious. Telling the client not to worry or ignoring the comment isn t supportive and doesn t o%%er reassurance. >4. A client tells the nurse that people %rom (ars are going to invade the earth. -hich response !y the nurse would !e most therapeutic" A. "1hat must be frightening to you. Can you tell me ho you feel about it!" &. "There are no people living on (ars." 2. "-hat do you mean when you say they re going to invade the earth"" D. ". /now you !elieve the earth is going to !e invaded, !ut . don t !elieve that." Rationale# This response addresses the client s underlying %ears without %eeding the delusion. Re%uting the client s delusion, as in option &, would increase an$iety and rein%orce the delusion. As/ing the client to ela!orate on the delusion, as in option 2, would also rein%orce it. Eoicing dis!elie% a!out the delusion, as in option D, wouldn t help the client deal with underlying %ears >;. A client with schi*ophrenia tells the nurse he hears the voices o% his dead parents. To help the client ignore the voices, the nurse should recommend that he# A. sit in a 'uiet, dar/ room and concentrate on the voices. B. listen to a personal stereo through headphones and sing along music. 2. call a %riend and discuss the voices and his %eelings a!out them. D. engage in strenuous e$ercise. ith the

Rationale# .ncreasing the amount o% auditory stimulation, such as !y listening to music through headphones, may ma/e it easier %or the client to %ocus on e$ternal sounds and ignore internal sounds %rom auditory hallucinations. 7ption A would ma/e it harder %or the client to ignore the hallucinations. Tal/ing a!out the voices, as in option 2, would encourage the client to %ocus on them. 7ption D is incorrect !ecause e$ercise alone wouldn t provide enough auditory stimulation to drown out the voices. >=. A client with schi*ophrenia is receiving antipsychotic medication. -hich nursing diagnosis may !e appropriate %or this client"

A. Ineffective protection related to blood dyscrasias &. 0rinary %re'uency related to adverse e%%ects o% antipsychotic medication 2. Ris/ %or in?ury related to a severely decreased level o% consciousness D. Ris/ %or in?ury related to electrolyte distur!ances Rationale# Antipsychotic medications may cause neutropenia and granulocytopenia, li%e8threatening !lood dyscrasias, that warrant a nursing diagnosis o% .ne%%ective protection related to !lood dyscrasias. These medications also have anticholinergic e%%ects, such as urine retention, dry mouth, and constipation. 0rinary %re'uency isn t an approved nursing diagnosis. Although antipsychotic medications may cause sedation, they don t severely decrease the level o% consciousness, eliminating option 2. These drugs don t cause electrolyte distur!ances, eliminating option D. >>. A client with persistent, severe schi*ophrenia has !een treated with phenothia*ines %or the past 1@ years. 3ow the client s speech is gar!led as a result o% drug8induced rhythmic tongue protrusion. -hat is another name %or this e$trapyramidal symptom" A. Dystonia &. A/athisia 2. Pseudopar/insonism ". 1ardive dyskinesia Rationale# An adverse reaction to phenothia*ines, tardive dys/inesia re%ers to chorei%orm tongue movements that commonly are irreversi!le and may inter%ere with speech. Dystonia re%ers to involuntary contraction o% a muscle group. A/athisia is restlessness or ina!ility to sit still. Pseudopar/insonism descri!es a group o% symptoms that mimic those o% Par/inson s disease. >@. The nurse is assigned to a client with catatonic schi*ophrenia. -hich intervention should the nurse include in the client s plan o% care" A. 'eeting all of the client(s physical needs &. Hiving the client an opportunity to e$press concerns 2. Administering lithium car!onate 5:ithonate6 as prescri!ed D. Providing a 'uiet environment where the client can !e alone Rationale# &ecause a client with catatonic schi*ophrenia can t meet physical needs independently, the nurse must provide %or all o% these needs, including ade'uate %ood and %luid inta/e, e$ercise, and elimination. This client is incapa!le o% e$pressing concerns9 however, the nurse should try to ver!ali*e the message conveyed !y the client s nonver!al !ehavior. :ithium is used to treat mania, not catatonic schi*ophrenia. Despite the client s mute, unresponsive state, the nurse should provide nonthreatening stimulation and should spend time with the client, not leave the client alone all the time. Although aware o% the environment, the client doesn t interact with it actively9 the nurse s support and presence can !e reassuring. >A. A client with a history o% medication noncompliance is receiving outpatient treatment %or chronic undi%%erentiated schi*ophrenia. The physician is most li/ely to prescri!e which medication %or this client" A. chlorproma*ine 5Thora*ine6

&. imipramine 5To%ranil6 2. lithium car!onate 5:ithane6 ". fluphena$ine decanoate %5rolixin "ecanoate& Rationale# ,luphena*ine decanoate is a long8acting antipsychotic agent given !y in?ection. &ecause it has a ;8wee/ duration o% action, it s commonly prescri!ed %or outpatients with a history o% medication noncompliance. 2hlorproma*ine, also an antipsychotic agent, must !e administered daily to maintain ade'uate plasma levels, which necessitates compliance with the dosage schedule. .mipramine, a tricyclic antidepressant, and lithium car!onate, a mood sta!ili*er, are rarely used to treat clients with chronic schi*ophrenia. >C. Propranolol 5.nderal6 is used in the mental health setting to manage which o% the %ollowing conditions" A. Antipsychotic-induced akathisia and anxiety &. The manic phase o% !ipolar illness as a mood sta!ili*er 2. Delusions %or clients su%%ering %rom schi*ophrenia D. 7!sessive8compulsive disorder 572D6 to reduce ritualistic !ehavior Rationale# Propranolol is a potent !eta8adrenergic !loc/er and produces a sedating e%%ect9 there%ore, it s used to treat antipsychotic induced a/athisia and an$iety. :ithium 5:itho!id6 is used to sta!ili*e clients with !ipolar illness. Antipsychotics are used to treat delusions. 1ome antidepressants have !een e%%ective in treating 72D. @<. Bvery day %or the past ) wee/s, a client with schi*ophrenia stands up during group therapy and screams, "Het out o% here right nowI The elevator !om!s are going to e$plode in 4 minutesI" The ne$t time this happens, how should the nurse respond" A. "-hy do you thin/ there is a !om! in the elevator"" &. "That is the same thing you said in yesterday s session." C. "I kno you think there are bombs in the elevator0 but there aren(t." D. ".% you have something to say, you must do it according to our group rules." Rationale# 7ption 2 is the most therapeutic response !ecause it orients the client to reality. 7ptions A and & are condescending. 7ption D sounds punitive and could em!arrass the client. @1. A )>8year8old client is admitted to the psychiatric unit with acute onset o% schi*ophrenia. +is physician prescri!es the phenothia*ine chlorproma*ine 5Thora*ine6, 1<< mg !y mouth %our times per day. &e%ore administering the drug, the nurse reviews the client s medication history. 2oncomitant use o% which drug is li/ely to increase the ris/ o% e$trapyramidal e%%ects" A. guanethidine 5.smelin6 B. droperidol %Inapsine& 2. lithium car!onate 5:ithonate6 D. alcohol Rationale# -hen administered with any phenothia*ine, droperidol may increase the ris/ o% e$trapyramidal e%%ects. The other options are incorrect

@). A client, age 4>, with paranoid schi*ophrenia !elieves the room is !ugged !y the 2entral .ntelligence Agency and that his roommate is a %oreign spy. The client has never had a romantic relationship, has no contact with %amily mem!ers, and hasn t !een employed in the last 1; years. &ased on Bri/son s theories, the nurse should recogni*e that this client is in which stage o% psychosocial development" A. Autonomy versus shame and dou!t &. Henerativity versus stagnation 2. .ntegrity versus despair ". 1rust versus mistrust Rationale# This client s paranoid ideation indicates di%%iculty trusting others. The stage o% autonomy versus shame and dou!t deals with separation, cooperation, and sel%8control. Henerativity versus stagnation is the normal stage %or this client s chronologic age. .ntegrity versus despair is the stage %or accepting the positive and negative aspects o% one s li%e, which would !e di%%icult or impossi!le %or this client. @4. During a group therapy session in the psychiatric unit, a client constantly interrupts with impulsive !ehavior and e$aggerated stories that cast her as a hero or princess. 1he also manipulates the group with attention8see/ing !ehaviors, such as se$ual comments and angry out!ursts. The nurse reali*es that these !ehaviors are typical o%# A. paranoid personality disorder. &. avoidant personality disorder. C. histrionic personality disorder. D. !order