NURS 3381 Exam 2 Questions With Complete Solutions
A newly admitted patient with schizophrenia says, "The voices
are bothering me. They yell and tell me I'm bad. I have got to
get away from them." Select the nurse's most helpful reply.
"I'll stay with you. Focus on what we are talking about, not the
voices."
A patient with schizophrenia has taken fluphenazine (Prolixin) 5
mg orally twice daily for 3 weeks. The nurse now assesses a
shuffling propulsive gait, a masklike face, and drooling. Which
term applies to these symptoms?
Pseudoparkinsonism
A patient with schizophrenia is acutely disturbed and violent.
After several doses of haloperidol (Haldol), the patient is calm.
Two hours later the nurse sees the patient's head rotated to one
side in a stiff position; the lower jaw is thrust forward, and the
patient is drooling. Which problem is most likely?
Acute dystonic reaction
An acutely violent patient with schizophrenia receives several
doses of haloperidol (Haldol). Two hours later the nurse notices
the patient's head rotated to one side in a stiffly fixed position;
the lower jaw is thrust forward, and the patient is drooling.
Which intervention by the nurse is indicated?
Administer diphenhydramine (Benadryl) 50 mg IM from the
PRN medication administration record.
,A patient has taken trifluoperazine (Stelazine) 30 mg/day orally
for 3 years. The clinic nurse notes that the patient grimaces and
constantly smacks both lips. The patient's neck and shoulders
twist in a slow, snakelike motion. Which problem would the
nurse suspect?
Tardive dyskinesia
A nurse sits with a patient diagnosed with disorganized
schizophrenia. The patient starts to laugh uncontrollably,
although the nurse has not said anything funny. Select the
nurse's best response.
"You're laughing. Tell me what's happening."
Which symptoms are expected for a patient with disorganized
schizophrenia?
Social withdrawal and ineffective communication
What assessment findings mark the prodromal stage of
schizophrenia?
Withdrawal, misinterpreting, poor concentration, and
preoccupation with religion
A patient with schizophrenia says, "Contagious bacteria are
everywhere. When they get in your body, you will be locked up
with other infected people." Which problem is evident?
Paranoia
,A patient diagnosed with paranoid schizophrenia angrily tells a
nurse, "You act like a homosexual. No one trusts you or wants
to be around you." Select the most likely analysis. The patient:
may be projecting homosexual urges.
A patient diagnosed with disorganized schizophrenia says, "It's
beat. Time to eat. No room for the cat." What type of
verbalization is evident?
Associative looseness
A patient with schizophrenia has taken a conventional
antipsychotic medication for a year. Hallucinations are less
intrusive, but the patient continues to have apathy, poverty of
thought, and social isolation. The nurse expects a change to
which medication?
olanzapine (Zyprexa)
The family of a patient with undifferentiated schizophrenia is
unfamiliar with the illness and the family's role in recovery.
Which type of therapy should the nurse recommend?
Psychoeducational
A patient with schizophrenia has been stable for a year;
however, the family now reports the patient is tense, sleeps 3 to
, 4 hours per night, and has difficulty concentrating. The patient
says, "Volmers are hiding in the house." The nurse can correctly
assess this information as an indication of:
relapse
A patient with schizophrenia begins to talks about "volmers"
hiding in the warehouse at work. The term "volmers" should be
documented as:
neologism
A patient with schizophrenia anxiously says, "I can see the left
side of my body merging with the wall, then my face appears
and disappears in the mirror." While listening, the nurse should:
maintain a normal social interaction distance from the patient.
A patient with schizophrenia and auditory hallucinations
anxiously tells the nurse, "The voice is telling me to do things."
Select the nurse's priority assessment question.
"What is the voice telling you to do?"
A patient receiving risperidone (Risperdal) reports severe
muscle stiffness at 10:30 AM. By noon, the patient has difficulty
swallowing and is drooling. By 4:00 PM, vital signs are body
temperature, 102.8° F; pulse, 110 beats per minute; respirations,
26 breaths per minute; and blood pressure, 150/90 mm Hg. The
patient is diaphoretic. Select the nurse's best analysis and action.
Neuroleptic malignant syndrome. Immediately notify the health
care provider.
A newly admitted patient with schizophrenia says, "The voices
are bothering me. They yell and tell me I'm bad. I have got to
get away from them." Select the nurse's most helpful reply.
"I'll stay with you. Focus on what we are talking about, not the
voices."
A patient with schizophrenia has taken fluphenazine (Prolixin) 5
mg orally twice daily for 3 weeks. The nurse now assesses a
shuffling propulsive gait, a masklike face, and drooling. Which
term applies to these symptoms?
Pseudoparkinsonism
A patient with schizophrenia is acutely disturbed and violent.
After several doses of haloperidol (Haldol), the patient is calm.
Two hours later the nurse sees the patient's head rotated to one
side in a stiff position; the lower jaw is thrust forward, and the
patient is drooling. Which problem is most likely?
Acute dystonic reaction
An acutely violent patient with schizophrenia receives several
doses of haloperidol (Haldol). Two hours later the nurse notices
the patient's head rotated to one side in a stiffly fixed position;
the lower jaw is thrust forward, and the patient is drooling.
Which intervention by the nurse is indicated?
Administer diphenhydramine (Benadryl) 50 mg IM from the
PRN medication administration record.
,A patient has taken trifluoperazine (Stelazine) 30 mg/day orally
for 3 years. The clinic nurse notes that the patient grimaces and
constantly smacks both lips. The patient's neck and shoulders
twist in a slow, snakelike motion. Which problem would the
nurse suspect?
Tardive dyskinesia
A nurse sits with a patient diagnosed with disorganized
schizophrenia. The patient starts to laugh uncontrollably,
although the nurse has not said anything funny. Select the
nurse's best response.
"You're laughing. Tell me what's happening."
Which symptoms are expected for a patient with disorganized
schizophrenia?
Social withdrawal and ineffective communication
What assessment findings mark the prodromal stage of
schizophrenia?
Withdrawal, misinterpreting, poor concentration, and
preoccupation with religion
A patient with schizophrenia says, "Contagious bacteria are
everywhere. When they get in your body, you will be locked up
with other infected people." Which problem is evident?
Paranoia
,A patient diagnosed with paranoid schizophrenia angrily tells a
nurse, "You act like a homosexual. No one trusts you or wants
to be around you." Select the most likely analysis. The patient:
may be projecting homosexual urges.
A patient diagnosed with disorganized schizophrenia says, "It's
beat. Time to eat. No room for the cat." What type of
verbalization is evident?
Associative looseness
A patient with schizophrenia has taken a conventional
antipsychotic medication for a year. Hallucinations are less
intrusive, but the patient continues to have apathy, poverty of
thought, and social isolation. The nurse expects a change to
which medication?
olanzapine (Zyprexa)
The family of a patient with undifferentiated schizophrenia is
unfamiliar with the illness and the family's role in recovery.
Which type of therapy should the nurse recommend?
Psychoeducational
A patient with schizophrenia has been stable for a year;
however, the family now reports the patient is tense, sleeps 3 to
, 4 hours per night, and has difficulty concentrating. The patient
says, "Volmers are hiding in the house." The nurse can correctly
assess this information as an indication of:
relapse
A patient with schizophrenia begins to talks about "volmers"
hiding in the warehouse at work. The term "volmers" should be
documented as:
neologism
A patient with schizophrenia anxiously says, "I can see the left
side of my body merging with the wall, then my face appears
and disappears in the mirror." While listening, the nurse should:
maintain a normal social interaction distance from the patient.
A patient with schizophrenia and auditory hallucinations
anxiously tells the nurse, "The voice is telling me to do things."
Select the nurse's priority assessment question.
"What is the voice telling you to do?"
A patient receiving risperidone (Risperdal) reports severe
muscle stiffness at 10:30 AM. By noon, the patient has difficulty
swallowing and is drooling. By 4:00 PM, vital signs are body
temperature, 102.8° F; pulse, 110 beats per minute; respirations,
26 breaths per minute; and blood pressure, 150/90 mm Hg. The
patient is diaphoretic. Select the nurse's best analysis and action.
Neuroleptic malignant syndrome. Immediately notify the health
care provider.
