A 19-year-old patient is admitted for the second time in 9 months and is
acutely psychotic with a diagnosis of undifferentiated schizophrenia. The
patient sits alone rubbing her arms and smiling. She tells the nurse her
thoughts cause earthquakes and that the world is burning. The nurse
assesses the primary deficit associated with the patients condition as:
a. Social isolation
b. Disturbed thinking
c. Altered mood states
d. Poor impulse control
B
The nurse interprets the patients statements that were not reality-based as
indicating disturbed thought processes.
A 34-year-old male admitted with catatonic schizophrenia has been mute
and motionless for several days while at home prior to admission. He still
appears stuporous in the hospital. Which nursing intervention would be an
initial priority?
a. Orienting the patient to the unit
b. Reinforcing reality with the patient
c. Establishing a nonthreatening relationship
d. Assessing the patient for physical problems
D
Patients who are mute and motionless and inattentive to environmental
stimuli are at risk for a number of physical problems. Further, they are
unable to communicate existing problems.
,An appropriate intervention for a patient with an identified nursing
diagnosis of situational low self-esteem would be:
a. Providing large muscle activities to relieve stress
b. Attempting to determine triggers to hallucinations
c. Engaging patient in activities designed to permit success
d. Encouraging verbalization of feelings in a safe environment
C
All are useful interventions for a patient with schizophrenia; however,
engaging the patient in specifically designed activities is the only option
that addresses improving self-esteem.
Because of the cognitive disturbances associated with schizophrenia, which
technique will be useful as the nurse teaches a patient about self-
management?
a. Use only verbal instruction.
b. Teach material in small segments.
c. Offer opportunities for making numerous choices.
d. Plan the teaching for a time when the patient has been recently
medicated.
B
Patients with cognitive disturbances should be taught small blocks of
information at a time and given frequent reinforcement.
, By discharge, which outcome is appropriate for a patient who hears voices
telling him he is evil?
a. Respond verbally to the voices.
b. Verbalize the reason the voices say he is evil.
c. Identify events that increase anxiety and promote hallucinations.
d. Integrate the voices into his personality structure in a positive manner.
C
An appropriate outcome for a patient with hallucinations is recognition of
events that precede the onset of hallucinations.
A client has been diagnosed with schizophrenia. He has been socially
isolated and is hearing voices telling him to kill his parents. He has been
admitted to the psychiatric unit from the emergency department. The initial
nursing intervention for Josh is to:
a. Give him an injection of haloperidol.
b. Assess his safety toward himself and others.
c. Place him in restraints.
d. Order him a nutritious diet.
B
A client on the psychiatric unit has been diagnosed with schizophrenia. He
tells the nurse that the CIA is looking for him and will kill him if they find
him. The most appropriate response by the nurse is:
a. "That's ridiculous. No one is going to hurt you."
b. "The CIA isn't interested in people like you."
c. "Why do you think the CIA wants to kill you?"
d. "I know you believe that, but it's really hard for me to believe."
D
acutely psychotic with a diagnosis of undifferentiated schizophrenia. The
patient sits alone rubbing her arms and smiling. She tells the nurse her
thoughts cause earthquakes and that the world is burning. The nurse
assesses the primary deficit associated with the patients condition as:
a. Social isolation
b. Disturbed thinking
c. Altered mood states
d. Poor impulse control
B
The nurse interprets the patients statements that were not reality-based as
indicating disturbed thought processes.
A 34-year-old male admitted with catatonic schizophrenia has been mute
and motionless for several days while at home prior to admission. He still
appears stuporous in the hospital. Which nursing intervention would be an
initial priority?
a. Orienting the patient to the unit
b. Reinforcing reality with the patient
c. Establishing a nonthreatening relationship
d. Assessing the patient for physical problems
D
Patients who are mute and motionless and inattentive to environmental
stimuli are at risk for a number of physical problems. Further, they are
unable to communicate existing problems.
,An appropriate intervention for a patient with an identified nursing
diagnosis of situational low self-esteem would be:
a. Providing large muscle activities to relieve stress
b. Attempting to determine triggers to hallucinations
c. Engaging patient in activities designed to permit success
d. Encouraging verbalization of feelings in a safe environment
C
All are useful interventions for a patient with schizophrenia; however,
engaging the patient in specifically designed activities is the only option
that addresses improving self-esteem.
Because of the cognitive disturbances associated with schizophrenia, which
technique will be useful as the nurse teaches a patient about self-
management?
a. Use only verbal instruction.
b. Teach material in small segments.
c. Offer opportunities for making numerous choices.
d. Plan the teaching for a time when the patient has been recently
medicated.
B
Patients with cognitive disturbances should be taught small blocks of
information at a time and given frequent reinforcement.
, By discharge, which outcome is appropriate for a patient who hears voices
telling him he is evil?
a. Respond verbally to the voices.
b. Verbalize the reason the voices say he is evil.
c. Identify events that increase anxiety and promote hallucinations.
d. Integrate the voices into his personality structure in a positive manner.
C
An appropriate outcome for a patient with hallucinations is recognition of
events that precede the onset of hallucinations.
A client has been diagnosed with schizophrenia. He has been socially
isolated and is hearing voices telling him to kill his parents. He has been
admitted to the psychiatric unit from the emergency department. The initial
nursing intervention for Josh is to:
a. Give him an injection of haloperidol.
b. Assess his safety toward himself and others.
c. Place him in restraints.
d. Order him a nutritious diet.
B
A client on the psychiatric unit has been diagnosed with schizophrenia. He
tells the nurse that the CIA is looking for him and will kill him if they find
him. The most appropriate response by the nurse is:
a. "That's ridiculous. No one is going to hurt you."
b. "The CIA isn't interested in people like you."
c. "Why do you think the CIA wants to kill you?"
d. "I know you believe that, but it's really hard for me to believe."
D
