Schizophrenia NCLEX Practice Quiz: 65 Questions | 2022 latest update

Schizophrenia NCLEX Practice Quiz: 65 Questions 1. Question Nurse Dorothy is evaluating care of a client with schizophrenia; the nurse should keep which point in mind? o A. Frequent reassessment is needed and is based on the client's response to treatment. o B. The family does not need to be included in the care because the client is an adult. o C. The client is too ill to learn about his illness. o D. Relapse is not an issue for a client with schizophrenia. Incorrect Correct Answer: A. Frequent reassessment is needed and is based on the client’s response to treatment. Because the client responds to treatment in different ways, the nurse must constantly evaluate the client and his potential. A premorbid adjustment must also be considered. Assess if incoherence in speech is chronic or if it is more sudden, as in an exacerbation of symptoms. Establishing a baseline facilitates the establishment of realistic goals, the foundation for planning effective care. • Option B: Most clients with such conditions go home, so the family should be involved. Inform the client’s family in clear, simple terms about psychopharmacologic therapy: dose, duration, indication, side effects, and toxic effects. Written information should be given to the client and family members as well. Understanding of the disease and the treatment of the disease encourages greater family support and client adherence. • Option C: The client can learn about the illness if the information is provided gradually. Use simple, concrete, and literal explanations. Minimizes misunderstanding and/or incorporating those misunderstandings into delusional systems. Use therapeutic techniques (clarifying feelings when speech and thoughts are disorganized) to try to understand the client’s concerns. Even if the words are hard to understand, try getting to the feelings behind them. • Option D: Relapse is common in schizophrenia. Educating patients on the importance of modifying risk factors such as increasing exercise, healthier diets, and smoking cessation will decrease their risk of cardiovascular problems and reduce the mortality rate. Moreover, cognitive behavioral therapy has been shown to improve patient compliance and decrease future hospital admissions. 2. 2. Question Gio told his nurse that the FBI is monitoring and recording his every movement and that microphones have been placed in the unit walls. Which action would be the most therapeutic response? • A. Confront the delusional material directly by telling Gio that this simply is not so. • B. Tell Gio that this must seem frightening to him but that you believe he is safe here. • C. Tell Gio to wait and talk about these beliefs in his one-on-one counseling sessions. • D. Isolate Gio when he begins to talk about these beliefs. Incorrect Correct Answer: B. Tell Gio that this must seem frightening to him but that you believe he is safe here. The nurse must realize that these perceptions are very real to the client. Acknowledging the client’s feelings provides support; explaining how the nurse sees the situation in a different way provides reality orientation. Recognize the client’s delusions as the client’s perception of the environment. Recognizing the client’s perception can help you understand the feelings he or she is experiencing. • Option A: Confronting the delusional material directly will not work with this client and may diminish trust. Attempt to understand the significance of these beliefs to the client at the time of their presentation. Important clues to underlying fears and issues can be found in the client’s seemingly illogical fantasies. • Option C: Telling the client to wait and talk about these beliefs in his one-on-one counseling session will reinforce the delusion. Initially do not argue with the client’s beliefs or try to convince the client that the delusions are false and unreal. Arguing will only increase a client’s defensive position, thereby reinforcing false beliefs. This will result in the client feeling even more isolated and misunderstood. • Option D: Isolation will increase anxiety. Distraction with a radio or activities would be a better approach. Interact with clients on the basis of things in the environment. Try to distract the client from their delusions by engaging in reality-based activities (e.g., card games, simple arts and crafts projects, etc). When thinking is focused on reality-based activities, the client is free of delusional thinking during that time. Helps focus attention externally. 3. 3. Question Which of the following client behaviors documented in Gio’s chart would validate the nursing diagnosis of Risk for other-directed violence? • A. Gio's description of being endowed with superpowers. • B. Frequent angry outburst noted toward peers and staff. • C. Refusal to eat cafeteria food. • D. Refusal to join in group activities. Incorrect Correct Answer: B. Frequent angry outburst noted toward peers and staff Anger is an important factor that indicates the potential for acting out. Because the client is angry with both peers and staff, any acting out would probably be directed toward others. Frequently assess client’s behavior for signs of increased agitation and hyperactivity. Early detection and intervention of escalating mania will prevent the possibility of harm to self or others, and decrease the need for seclusions. • Option A: The client’s description of being endowed with superpowers indicates he is having delusions. Attempt to understand the significance of these beliefs to the client at the time of their presentation. Important clues to underlying fears and issues can be found in the client’s seemingly illogical fantasies. Recognize the client’s delusions as the client’s perception of the environment. • Option C: His refusal to eat cafeteria food indicates that he may have delusional beliefs, but not necessarily a risk for violence. Do not touch the client; use gestures carefully. Suspicious clients might misinterpret touch as either aggressive or sexual in nature and might interpret it as a threatening gesture. People who are psychotic need a lot of personal space. • Option D: Refusal to join in group activities indicates discomfort with a group, however, no threat of violence is apparent. Structure times each day to include planned times for brief interactions and activities with the client on one-on-one basis. Helps the client to develop a sense of safety in a non-threatening environment. Provide opportunities for the client to learn adaptive social skills in a non-threatening environment. Initial social skills training could include basic social behaviors (e.g., appropriate distance, maintain good eye contact, calm manner/behavior, moderate voice tone). 4. 4. Question Nurse Winona educates the family about symptom management for when the schizophrenic client becomes upset or anxious. Which of the following would Nurse Winona state be helpful? • A. Call the therapist to request a medication change. • B. Encourage the use of learned relaxation techniques. • C. Request that the client be hospitalized until the crisis is over. • D. Wait before the anxiety worsens before intervening. Incorrect Correct Answer: B. Encourage the use of learned relaxation techniques. The client with schizophrenia can learn relaxation techniques, which help reduce anxiety. The family can be supportive and helpful by encouraging the client to use these techniques. When client is ready, introduce strategies that can minimize anxiety and lower voices and “worrying” thoughts, teach client to do the following: focus on meaningful activities; learn to replace negative thoughts with constructive thoughts; perform deep breathing exercise; use a calming visualization or listen to music; or seek support from staff, family, or other supportive people. • Option A: Anxiety is a common experience for everyone, and is no reason to change medication. Handling anxiety is a learned skill that is important to reinforce. Keep the environment calm, quiet and as free of stimuli as possible to keep anxiety from escalating and increasing confusion and hallucinations/delusions. • Option C: There is no indication that the client is in crisis. Use therapeutic techniques (clarifying feelings when speech and thoughts are disorganized) to try to understand the client’s concerns. Even if the words are hard to understand, try getting to the feelings behind them. • Option D: It is much easier to intervene early in anxiety rather than waiting until escalation occurs. Assess and observe clients regularly for signs of increasing anxiety and hostility. Intervene before the client loses control. Use a non-judgmental, respectful, and neutral approach with the client. There is less chance for a suspicious client to misinterpret intent or meaning if the content is neutral and the approach is respectful and non-judgemental. 5. 5. Question Drogo, who has had auditory hallucinations for many years, tells Nurse Khally that the voices prevent his participation in a social skills training program at the community health center. Which intervention is most appropriate? • A. Let Drogo analyze the content of the voices. • B. Advise Drogo to participate in the program when the voices cease. • C. Advise Drogo to take his medications as prescribed. • D. Teach Drogo to use thought-stopping techniques. Incorrect Correct Answer: D. Teach Drogo to use thought-stopping techniques. Clients with long-lasting auditory hallucinations can learn to use thought-stopping measures to accomplish tasks. In this technique, when the obsessive or racing thoughts begin, the client says, clearly and distinctly, “Stop!” This then allows the client to substitute a new, healthier thought. Many therapists encourage the client to, at first, yell out the “Stop!” This helps focus the attention on the word and away from the obsessive thought. Later, the client will be able to mentally yell the word to themselves without needing to say it aloud. • Option A: Analyzing the content of the voices may be indicated when hallucinations first occur to establish whether the voices are threatening to the client or instructing him to harm others. However, focusing on their content at this point would reinforce this symptom. Keep to simple, basic, reality-based topics of conversation. Help the client focus on one idea at a time. Client’ thinking might be confused and disorganized; this intervention helps the client focus and comprehend reality-based issues. • Option B: The voices have lasted many years; the client should participate despite the voices. Work with the client to find which activities help reduce anxiety and distract the client from hallucinatory material. Practice new skills with the client. If clients’ stress triggers hallucinatory activity, they might be more motivated to find ways to remove themselves from a stressful environment or try distraction techniques. • Option D: There is no indication that the client is not taking medication as prescribed. Stay with clients when they are starting to hallucinate, and direct them to tell the “voices they hear” to go away. Repeat often in a matter-of-fact manner. The client can sometimes learn to push voices aside when given repeated instructions. especially within the framework of a trusting relationship. Intervene with one-on-one, seclusion, or PRN medication (As ordered) when appropriate. 6. 6. Question Cersei is diagnosed as having disorganized schizophrenia. Which behaviors would Nurse Sansa most likely assess in the client? • A. Absence of acute symptoms impaired role function. • B. Extreme social withdrawal, odd mannerisms, and behavior. • C. Psychomotor immobility; presence of waxy flexibility. • D. Suspiciousness toward others increased hostility. Incorrect Correct Answer: B. Extreme social withdrawal, odd mannerisms, and behavior Disorganized schizophrenia is characterized by regressive behavior with extreme social withdrawal and frequently odd mannerisms. In the most general sense, disorganized schizophrenia refers to the disorganization of thought processes, behavior, and affect regulation (emotions). The DSM-IV included five subtypes of schizophrenia, including disorganized, paranoid, catatonic, undifferentiated, and residual. The subtypes were removed from the current version of the DSM (DSM-5, released in 2013), as it was determined that they were not helpful when treating the disorder. • Option A: The absence of acute symptoms and impaired role function are more characteristic of residual-type schizophrenia. Residual-type schizophrenia is characterized by a past history of at least one episode of schizophrenia, but the person will currently have no positive symptoms (delusions, hallucinations, disorganized speech or behavior). Symptoms may represent a transition between a full-blown episode and complete remission, or it may continue for years without any further psychotic episodes. • Option C: Psychomotor immobility and presence of waxy flexibility are more indicative of catatonic schizophrenia. Catatonia is a complex combination of psychomotor abnormalities and mood and thought processes. There are at least forty different signs and symptoms that have been associated with catatonia. The Diagnostic and Statistical Manual V has criteria for catatonia with specifiers, including that for schizophrenia. • Option D: Suspiciousness toward others and increased hostility is more characteristic of paranoid schizophrenia. Paranoid schizophrenia is characterized by predominantly positive symptoms of schizophrenia, including delusions and hallucinations. These debilitating symptoms blur the line between what is real and what isn’t, making it difficult for the person to lead a typical life. 7. 7. Question Jaime has a diagnosis of schizophrenia with negative symptoms. In planning care for the client, Nurse Brienne would anticipate a problem with: • A. Auditory hallucinations • B. Bizarre behaviors • C. Ideas of reference • D. Motivation for activities Incorrect Correct Answer: D. Motivation for activities. In a client demonstrating negative symptoms of schizophrenia, avolition, or the lack of motivation for activities, is a common problem. These “negative” symptoms are so-called because they are an absence as much as a presence: inexpressive faces, blank looks, monotone, and monosyllabic speech, few gestures, seeming lack of interest in the world and other people, inability to feel pleasure or act spontaneously. It is important to distinguish between lack of expression and lack of feeling, between lack of will and lack of activity. When questioned, patients with schizophrenia often express a full range of feelings and desires. • Option A: Schizophrenia causes a surplus of mental experiences (thoughts, feelings, behaviors). For example, hallucinations, which are not part of the normal, day-to-day experience for most people, are classified as a positive symptom for people with schizophrenia. The phrase “positive symptoms” refers to symptoms that are in ?excess or added to normal mental functioning. • Option B: Another positive symptom of schizophrenia is disorganized or abnormal movements or motor behaviors. An example of this is catatonic behavior, which involves a decreased reactivity to the environment. Catatonia is marked by a significant decrease in someone’s reactivity to their environment. This can involve stupor, mutism, negativism or motor rigidity, and even purposeless excitement. • Option C: A belief that gestures, comments, or other cues have special meaning directed at oneself. Delusions can be bizarre, such as the belief that one’s organs have been removed by aliens, or non-bizarre, such as believing one is under surveillance by the police. 8. 8. Question The family of a schizophrenic client asks the nurse if there is a genetic cause of this disorder. To answer the family, which fact would the nurse cite? • A. Conclusive evidence indicates a specific gene transmits the disorder. • B. Incidence of this disorder is variable in all families. • C. There is a little evidence that genes play a role in transmission. • D. Genetic factors can increase the vulnerability for this disorder. Incorrect Correct Answer: D. Genetic factors can increase the vulnerability for this disorder. Research shows that family history statistically increases the risk for the development of schizophrenia. Genetics also play a fundamental role – there is a 46% concordance rate in monozygotic twins and a 40% risk of developing schizophrenia if both parents are affected. The gene neuregulin (NGR1) which is involved in glutamate signaling and brain development has been implicated, alongside dysbindin (DTNBP1) which helps glutamate release, and catecholamine O-methyltransferase (COMT) polymorphism, which regulates dopamine function. • Option A: However, no single gene has yet been identified. Several studies postulate that the development of schizophrenia results from abnormalities in multiple neurotransmitters, such as dopaminergic, serotonergic, and alpha-adrenergic hyperactivity or glutaminergic and GABA hypoactivity. • Option B: This is incorrect because genetics plays a role in the etiology of schizophrenia. The incidence is also up to ten times greater in children of African and Caribbean migrants compared to Caucasians according to a study conducted in Britain. The association between cannabis use and psychosis has been widely studied, with recent longitudinal studies suggesting a 40% increased risk, while also suggesting a dose-effect relationship between the use of the drug and the risk of developing schizophrenia. • Option C: The neurochemical abnormality hypothesis argues that an imbalance of dopamine, serotonin, glutamate, and GABA results in the psychiatric manifestations of the disease. It postulates that four main dopaminergic pathways are involved in the development of schizophrenia. This dopamine hypothesis attributes the positive symptoms of the illness to excessive activation of D2 receptors via the mesolimbic pathway, while low levels of dopamine in the nigrostriatal pathway are theorized to cause motor symptoms through their effect on the extrapyramidal system. Low mesocortical dopamine levels resulting from the mesocortical pathway are thought to elicit the negative symptoms of the disease. 9. 9. Question Ramsay is diagnosed with schizophrenia paranoid type and is admitted to the psychiatric unit of Nurseslabs Medical Center. Which of the following nursing interventions would be most appropriate? • A. Establishing a non-demanding relationship. • B. Encouraging involvement in group activities. • C. Spending more time with Ramsay. • D. Waiting until Ramsay initiates interaction. Incorrect Correct Answer: A. Establishing a non-demanding relationship A non-threatening, non-demanding relationship helps decrease the mistrust that is common in a client with paranoid schizophrenia. Use a non-judgemental, respectful, and neutral approach with the client. There is less chance for a suspicious client to misinterpret intent or meaning if content is neutral and approach is respectful and non-judgemental. • Option B: Maintain a low level of stimuli and enhance a non-threatening environment (avoid groups). Noisy environments might be perceived as threatening. Initially, provide solitary, non-competitive activities that take some concentration. Later a game with one or more the client takes concentration (e.g., chess checkers, thoughtful card games such as ridge or rummy). If a client is suspicious of others, solitary activities are the best. Concentrating on environmental stimuli minimizes paranoid rumination. • Option C: Spending more time with the client would be threatening for a client who is suspicious of other people’s motives. Set limits in a clear matter-of-fact way, using a calm tone. “Giving threatening remarks to Jeremy is unacceptable. We can talk more about the proper ways in dealing with your feelings”. A calm and neutral approach may diffuse the escalation of anger. Offer an alternative to verbal abuse by finding appropriate ways to deal with feelings. • Option D: This client is unlikely to initiate interaction; the nurse is responsible for initiating a relationship with the client. Be honest and consistent with the client regarding expectations and enforcing rules. Suspicious people are quick to discern honesty. Honesty and consistency provide an atmosphere in which trust can grow. 10. 10. Question A client tells the nurse that psychotropic medicines are dangerous and refuses to take them. Which intervention should the nurse use first? • A. Ask the client about any previous problems with psychotropic medications. • B. Ask the client if an injection is preferable. • C. Insist that the client takes medication as prescribed. • D. Withhold the medication until the client is less suspicious. Incorrect Correct Answer: A. Ask the client about any previous problems with psychotropic medications. The nurse needs to clarify the client’s previous experience with psychotropic medication in order to understand the meaning of the client’s statement. Attempt to understand the significance of these beliefs to the client at the time of their presentation. Important clues to underlying fears and issues can be found in the client’s seemingly illogical fantasies. Explain the procedures and try to be sure the client understands the procedures before carrying them out. When the client has full knowledge of procedures, he or she is less likely to feel tricked by the staff. • Option B: Asking the client if an injection is preferable may add to the client’s suspicion and feeling threatened. Show empathy regarding the client’s feelings; reassure the client of your presence and acceptance. The client’s delusion can be distressing. Empathy conveys your caring, interest and acceptance of the client. • Option C: Insisting that the client take medication can be a violation of his right to refuse treatment. Initially do not argue with the client’s beliefs or try to convince the client that the delusions are false and unreal. Arguing will only increase a client’s defensive position, thereby reinforcing false beliefs. This will result in the client feeling even more isolated and misunderstood. • Option D: Withholding medication prescribed to relieve delusional beliefs will likely intensify paranoid thinking. Encourage healthy habits to optimize functioning: Maintain medication regimen; maintain regular sleep pattern; maintain self-care; and reduce alcohol and drug intake. All are vital to help keep the client in remission. 11. 11. Question Upon Sam’s admission for acute psychiatric hospitalization, Nurse Jona documents the following: Client refuses to bathe or dress, remains in the room most of the day, speaks infrequently to peers or staff. Which nursing diagnosis would be the priority at this time? • A. Anxiety • B. Decisional conflict • C. Self-care deficit • D. Social isolation Incorrect Correct Answer: D. Social isolation These behaviors indicate the client’s withdrawal from others and possible fear or mistrust of relationships. If a client is found to be very paranoid, solitary or one-on-one activities that require concentration are appropriate. The client is free to choose his level of interaction; however, concentration can help minimize distressing paranoid thoughts or voices. If a client is unable to respond verbally or in a coherent manner, spend a frequent, short period with clients. An interested presence can provide a sense of being worthwhile. • Option A: Keep the client in an environment as free of stimuli (loud noises, crowding) as possible. The client might respond to noises and crowding with agitation, anxiety, and increased inability to concentrate on outside events. Identify with client symptoms he experiences when he or she begins to feel anxious around others. Increased anxiety can intensify agitation, aggressiveness, and suspiciousness. • Option B: There is no indication of a Decisional conflict in the information provided. Structure times each day to include planned times for brief interactions and activities with the client on a one-on-one basis; helps the client to develop a sense of safety in a non-threatening environment. If the client is very withdrawn, one-on-one activities with a “safe” person initially should be planned. Learn to feel safe with one person, then gradually might participate in a structured group activity. • Option C: Although the client refuses to bathe or dress, Self-care deficit would not be the priority nursing diagnosis in this situation. Try to incorporate the strengths and interests the client had when not as impaired into the activities planned. Increase the likelihood of client’s participation and enjoyment. Remember to give acknowledgment and recognition for positive steps the client takes in increasing social skills and appropriate interactions with others. Recognition and appreciation go a long way to sustaining and increasing a specific behavior. 12. 12. Question Which statement is correct about a 25-year-old client with newly diagnosed schizophrenia? • A. Age of onset is typical for schizophrenia. • B. Age of onset is later than usual for schizophrenia. • C. Age of onset is earlier than usual for schizophrenia. • D. Age of onset follows no predictable pattern in schizophrenia. Incorrect Correct Answer: A. Age of onset is typical for schizophrenia. The primary age of onset for schizophrenia is late adolescence through young adulthood (ages 17 to 27). Paranoid schizophrenia may sometimes have a later onset. The incidence is also up to ten times greater in children of African and Caribbean migrants compared to Caucasians according to a study conducted in Britain. All of the other options are incorrect. • Option B: The first schizophrenic episode usually occurs during early adulthood or late adolescence. Individuals often lack insight at this stage; therefore few will present directly to seek help for their psychotic symptoms. Common presentations include a relative noticing social withdrawal, personality changes or uncharacteristic behavior; deliberate self-harm or suicide attempts; calling the police to report their delusional symptoms or referral via the criminal justice system. • Option C: In schizophrenia, the prognosis is dependent on several factors. Insidious onset, childhood or adolescent onset, poor premorbid adjustment, and cognitive impairment are indicative of a poor prognostic outcome whereas acute onset, female sex, and living in a developed country signal comparatively better prognostic factors. • Option D: Though the prevalence of the disease varies globally, estimates are that schizophrenia affects approximately 1% of adults, whereas prevalence in the US is 0.6% to 1.9%. Men are slightly more likely to be diagnosed and have an earlier onset than women, while African-Caribbean migrants and their descendants also have a higher incidence. 13. 13. Question Which factor is associated with increased risk for schizophrenia? • A. Alcoholism • B. Adolescent pregnancy • C. Overcrowded schools • D. Poverty Incorrect Correct Answer: D. Poverty Low socioeconomic status or poverty is an identified environmental factor associated with an increased incidence of schizophrenia. A criticism of this research field, which is in fact a criticism relevant to much social science research, is that the investigation of socio-environmental factors in the environment invariably focuses on poverty and deprivation to the exclusion of other important variables. One such variable is income inequality. Income inequality is a measure of the ‘rich-poor gap’ in any given society and therefore it exists at the ecological level. • Option A: Harmful alcohol and other drug use, particularly cannabis and amphetamine use, may trigger psychosis in people who are vulnerable to developing schizophrenia. While substance use does not cause schizophrenia, it is strongly related to relapse. People with schizophrenia are more likely than the general population to use alcohol and other drugs, and this is detrimental to treatment. • Option B: There are also arguments that schizophrenia is a neurodevelopmental disorder based on abnormalities present in the cerebral structure, an absence of gliosis suggesting in utero changes, and the observation that motor and cognitive impairments in patients precede the illness onset. Risk factors include birthing complications, the season of birth, severe maternal malnutrition, maternal influenza in pregnancy, family history, childhood trauma, social isolation, cannabis use, minority ethnicity, and urbanization. • Option C: Although overcrowded schools may be stressful, research does not show they increase the risk of schizophrenia. Socio-environmental risk factors for schizophrenia can be classified in terms of individual factors and neighborhood-level or ecological factors. Individual factors include unemployment, low socioeconomic status, and migration (Byrne et al, 2004; Cooper, 2005; Marwaha & Johnson, 2004; Subramanian & Kawachi, 2004), while neighborhood-level factors include urbanicity, ethnic density, and deprivation (Kirkbride et al, 2007; Krabbendam & van Os, 2005; van Os et al, 2005). 14. 14. Question Nurse Arya assesses for evidence of positive symptoms of schizophrenia in a newly admitted client. Which of the following symptoms are considered positive evidence? Select all that apply. • A. Anhedonia • B. Delusions • C. Flat affect • D. Hallucinations • E. Loose associations • F. Social withdrawal Incorrect Correct Answers: B, D, E These are considered positive symptoms of schizophrenia. The typical positive symptoms of schizophrenia, such as hallucinatory experiences or fixed delusional beliefs, tend to be very upsetting and disruptive—not a positive experience at all for you or someone you care about who is experiencing them. From the outside, a person with positive symptoms might seem distracted, as if they are listening to something (psychiatrists call this “responding to internal stimuli”). The phrase “positive symptoms” refers to symptoms that are in ?excess or added to normal mental functioning. • Option A: In Greek, an means “without” and hedone means “pleasure,” so in simple terms, anhedonia is a state where you are unable to feel pleasure. For people with schizophrenia, this can mean a lack of enthusiasm for activities, hobbies, passions, and pleasures once enjoyed. • Option B: Delusions are ideas that are not true. For example, people with schizophrenia might believe that the secret service is out to get them, or that TV anchors are transmitting coded messages, or their food is poisoned—and without any evidence. A fairly common type of delusion in schizophrenia is paranoia, which can cause a person with schizophrenia to feel followed, under close monitoring and surveillance, or afraid of ongoing plots or threats. • Option C: This limits a person’s ability to convey his or her emotions, causing diminished facial and emotional expressions. A blunted affect is less severe than flat affect, in which a person has an extremely limited range of emotions; for instance, not even being able to crack a smile or laugh during a time of great joy. • Option D: Schizophrenia causes a surplus of mental experiences (thoughts, feelings, behaviors). For example, hallucinations, which are not part of the normal, day-to-day experience for most people, are classified as positive symptom for people with schizophrenia. People with schizophrenia can experience a variety of hallucinations, but the most common are auditory hallucinations (or hearing noises and voices). This can include clicks and knocks, full conversations between people, or voices that talk to them directly. The voices can be good, but more often they are bad, dismissive, and mean. At times, the voices can be in the form of commands. • Option E: Disorganized thinking can be extremely frustrating, making it nearly impossible for people with schizophrenia to keep their thoughts straight or express what’s on their minds. This positive symptom causes a series of disjointed thoughts, making it hard to follow or make sense of what a loved one with schizophrenia is trying to say. Loose associations refer to illogical thinking or disconnected thoughts. • Option F: Other terms used to describe asociality are nonsocial, unsocial, social disinterest, or a lack of social drive. Asociality causes a lack of involvement in social relationships or an increased desire to spend time alone. This is different from a person who isolates him or herself after hearing voices or experiencing feelings of paranoia. 15. 15. Question A client with schizophrenia is referred for psychosocial rehabilitation. Which of the following are typical of this type of program? Select all that apply. • A. Analyzing family issues and past problems • B. Developing social skills and supports • C. Learning how to live independently in a community • D. Learning job skills for employment • E. Treating family members affected by the illness • F. Participating in in-depth psychoanalytical counseling Incorrect Correct Answer: B, C, D The goal of psychosocial rehabilitation as a treatment method is to help the client develop the skills and supports necessary for successful living, learning, and working in the community. Analysis of family issues and past problems and treatment of family members are not commonly part of this type of program. The emphasis of psychosocial rehabilitation is on the client’s development of skills in the here and now; consequently, psychoanalytic counseling is not part of the approach. • Option A: People may be left feeling demoralized as a result of their condition; rehabilitation focuses on helping clients feel hopeful about the future. Each individual needs to feel that they are able to set their own goals and have the power and autonomy to pursue those aims. • Option B: PSR is a treatment approach designed to help improve the lives of people with disabilities. The goal of psychosocial rehabilitation is to teach emotional, cognitive, and social skills that help those diagnosed with mental illness live and work in their communities as independently as possible. • Option C: PSR utilizes what is known as the recovery model of mental illness. Full recovery is frequently the goal, but full recovery is seen as a process rather than an outcome. This approach is centered on the person’s potential for recovery and focused on providing empowerment, social inclusion, support, and coping skills. • Option D: Rehabilitation aims to teach people skills to help them manage their condition and live the life they want to live. This includes living skills, work skills, social skills, and others. Mental health professionals should offer support and help clients build relationships and social connections in their community. • Option E: PSR treatments are multidisciplinary and often biopsychosocial in nature. This perspective recognizes that mental illness impacts multiple areas of life including the biological, social, and psychological systems. Not only are each of these systems affected by mental conditions but they are also inextricably interlinked. When something affects one area, it is bound to have an influence on other areas as well. • Option F: PSR takes a whole-person approach and recognizes that other mental health professionals and physicians may be needed to make contributions to the treatment process. Individual care may require a mixture of services and effective treatment. This often requires the facilitation of access to care from different domains. A team approach ensures that the person has access to the tools and resources needed to achieve the stated goals. 16. 16. Question The nurse is caring for a client with schizophrenia. Which of the following outcomes is the least desirable? • A. The client spends more time by himself. • B. The client doesn’t engage in delusional thinking. • C. The client doesn’t harm himself or others. • D. The client demonstrates the ability to meet his own self-care needs. Incorrect Correct Answer: A. The client spends more time by himself. The client with schizophrenia is commonly socially isolated and withdrawn; therefore, having the client spend more time by himself wouldn’t be a desirable outcome. Rather, a desirable outcome would specify that the client spends more time with other clients and staff on the unit. Delusions are false personal beliefs. Eventually engage other clients and significant others in social interactions and activities with the client (card games, ping pong, sing-a-songs, group sharing activities) at the client’s level. Client continues to feel safe and competent in a graduated hierarchy of interactions. • Option B: Reducing or eliminating delusional thinking using talking therapy and antipsychotic medications would be a desirable outcome. If the client is delusional/hallucinating or is having trouble concentrating at this time, provide very simple concrete activities with the client (e.g., looking at a picture or doing a painting). Even simple activities help draw the client away from delusional thinking into reality in the environment. • Option C: Protecting the client and others from harm is a desirable client outcome achieved by close observation, removing any dangerous objects, and administering medications. Ensure that the goals set are realistic; whether in the hospital or community. Avoids pressure on the client and sense of failure on part of the nurse/family. This sense of failure can lead to mutual withdrawal. • Option D: Because the client with schizophrenia may have difficulty meeting his or her own self-care needs, fostering the ability to perform self-care independently is a desirable client outcome. Remember to give acknowledgement and recognition for positive steps the client takes in increasing social skills and appropriate interactions with others. Recognition and appreciation go a long way to sustaining and increasing a specific behavior. 17. 17. Question The nurse formulates a nursing diagnosis of Impaired verbal communication for a client with schizotypal personality disorder. Based on this nursing diagnosis, which nursing intervention is most appropriate? • A. Helping the client to participate in social interactions. • B. Establishing a one-on-one relationship with the client. • C. Establishing alternative forms of communication. • D. Allowing the client to decide when he wants to participate in verbal communication with the nurse. Incorrect Correct Answer: B. Establishing a one-on-one relationship with the client By establishing a one-on-one relationship, the nurse helps the client learn how to interact with people in new situations. Assess if incoherence in speech is chronic or if it is more sudden, as in an exacerbation of symptoms. Establishing a baseline facilitates the establishment of realistic goals, the foundation for planning effective care. • Option A: Plan short, frequent periods with a client throughout the day. Short periods are less stressful, and periodic meetings give a client a chance to develop familiarity and safety. Keep voice in a low manner and speak slowly as much as possible. A high-pitched/loud tone of voice can elevate anxiety levels while slow speaking aids understanding. • Option C: Keep the environment calm, quiet and as free of stimuli as possible. Keep anxiety from escalating and increasing confusion and hallucinations/delusions. Use clear or simple words, and keep directions simple as well. The client might have difficulty processing even simple sentences. Use simple, concrete, and literal explanations. Minimizes misunderstanding and/or incorporating those misunderstandings into delusional systems. • Option D: The other options are appropriate but should take place only after the nurse-client relationship is established. Use therapeutic techniques (clarifying feelings when speech and thoughts are disorganized) to try to understand the client’s concerns. Even if the words are hard to understand, try getting to the feelings behind them. When you do not understand a client, let him/her know you are having difficulty understanding. Pretending to understand limits your credibility in the eyes of your client and lessens the potential for trust. 18. 18. Question Since admission 4 days ago, a client has refused to take a shower, stating, “There are poison crystals hidden in the showerhead. They’ll kill me if I take a shower.” Which nursing action is most appropriate? • A. Dismantling the showerhead and showing the client that there is nothing in it. • B. Explaining that other clients are complaining about the client’s body odor. • C. Asking a security officer to assist in giving the client a shower. • D. Accepting these fears and allowing the client to take a sponge bath. Incorrect Correct Answer: D. Accepting these fears and allowing the client to take a sponge bath By acknowledging the client’s fears, the nurse can arrange to meet the client’s hygiene needs in another way. Attempt to understand the significance of these beliefs to the client at the time of their presentation. Important clues to underlying fears and issues can be found in the client’s seemingly illogical fantasies. Recognize the client’s delusions as the client’s perception of the environment. Recognizing the client’s perception can help you understand the feelings he or she is experiencing. • Option A: Because these fears are real to the client, providing a demonstration of reality wouldn’t be effective at this time. Interact with clients on the basis of things in the environment. Try to distract the client from their delusions by engaging in reality-based activities (e.g., card games, simple arts and crafts projects etc). When thinking is focused on reality-based activities, the client is free of delusional thinking during that time. Helps focus attention externally. • Option B: Initially do not argue with the client’s beliefs or try to convince the client that the delusions are false and unreal. Arguing will only increase a client’s defensive position, thereby reinforcing false beliefs. This will result in the client feeling even more isolated and misunderstood. • Option C: These would violate the client’s rights by shaming or embarrassing the client. Do not touch the client; use gestures carefully. Suspicious clients might misinterpret touch as either aggressive or sexual in nature and might interpret it as a threatening gesture. People who are psychotic need a lot of personal space. 19. 19. Question Drug therapy with thioridazine (Mellaril) shouldn’t exceed a daily dose of 800 mg to prevent which adverse reaction? • A. Hypertension • B. Respiratory arrest • C. Tourette syndrome • D. Retinal pigmentation Incorrect Correct Answer: D. Retinal pigmentation Retinal pigmentation may occur if the thioridazine dosage exceeds 800 mg per day. The development of pigmentary retinopathy is a unique adverse manifestation associated with thioridazine, and not with other antipsychotics. Patients may have nonspecific symptoms while taking thioridazine, such as dry mouth, dry eyes, sedation, weight gain, dizziness, erectile dysfunction, pruritus, photosensitivity, and constipation. Other rare and more unique side effects of thioridazine include irreversible retinal pigmentation, poikilothermia, and agranulocytosis. • Option A: Thioridazine is associated with prolonged QTc intervals, which may have serious or even fatal consequences, such as Torsades de pointes. The recommendation is that patients with known prolonged QTc or arrhythmias avoid thioridazine. Before starting this medication, it would be wise to order an ECG and monitor for QTc prolongation or other ECG changes during treatment. • Option B: Respiratory arrest is not an adverse effect of thioridazine. NMS is another serious side effect of all antipsychotics and occurs more frequently with typical antipsychotics. This adverse effect may occur suddenly. The provider should monitor for unstable vital signs, such as tachycardia, fever, muscle rigidity, elevated white blood cell count, and creatinine phosphokinase. • Option C: The other options don’t occur as a result of exceeding this dose. Similar to other typical antipsychotics, thioridazine is associated with a risk of developing EPS. Because it is a low potency antipsychotic, however, the development of EPS occurs less frequently than with high potency antipsychotics. Extrapyramidal side effects include symptoms of dystonia, parkinsonism, and tardive dyskinesia. Dystonic reactions are muscle spasms that may occur early on and involve the eyes, tongue, or neck. 20. 20. Question A client with paranoid personality disorder is admitted to a psychiatric facility. Which remark by the nurse would best establish rapport and encourage the client to confide in the nurse? • A. “I get upset once in a while, too.” • B. “I know just how you feel. I’d feel the same way in your situation.” • C. “I worry, too, when I think people are talking about me.” • D. “At times, it’s normal not to trust anyone.” Incorrect Correct Answer: A. “I get upset once in a while, too.” Sharing a benign, non-threatening, personal fact or feeling helps the nurse establish rapport and encourages the client to confide in the nurse. The nurse can’t know how the client feels. Identify with the client symptoms he experiences when he or she begins to feel anxious around others. Increased anxiety can intensify agitation, aggressiveness, and suspiciousness. If a client is found to be very paranoid, solitary or one-on-one activities that require concentration are appropriate. The client is free to choose his level of interaction; however, concentration can help minimize distressing paranoid thoughts or voices. • Option B: Telling the client otherwise would justify the suspicions of a paranoid client; furthermore, the client relies on the nurse to interpret reality. Attempt to understand the significance of these beliefs to the client at the time of their presentation. Important clues to underlying fears and issues can be found in the client’s seemingly illogical fantasies. Initially do not argue with the client’s beliefs or try to convince the client that the delusions are false and unreal. • Option C: This is incorrect because it focuses on the nurse’s feelings, not the client’s. Recognize the client’s delusions as the client’s perception of the environment. Recognizing the client’s perception can help you understand the feelings he or she is experiencing. • Option D: This wouldn’t help establish rapport or encourage the client to confide in the nurse. Show empathy regarding the client’s feelings; reassure the client of your presence and acceptance. The client’s delusion can be distressing. Empathy conveys your caring, interest, and acceptance of the client. Interact with clients on the basis of things in the environment. Try to distract the client from their delusions by engaging in reality-based activities (e.g., card games, simple arts and crafts projects etc). 21. 21. Question How soon after chlorpromazine (Thorazine) administration should the nurse expect to see a client’s delusional thoughts and hallucinations eliminated?A. Several minutes • A. Several minutes • B. Several hours • C. Several days • D. Several weeks Incorrect Correct Answer: D. Several weeks Although most phenothiazines produce some effects within minutes to hours, their antipsychotic effects may take several weeks to appear. It can take a few days for chlorpromazine to take effect. It’s difficult to determine how long one can expect to wait, as the medication affects each person differently. Ideally, the client should stay on an antipsychotic medication for four to six weeks before deciding whether to continue taking it in the long term. This gives the medication a chance to build up in the system and to begin delivering its full effects. • Option A: This medication is used to treat certain mental/mood disorders (such as schizophrenia, psychotic disorders, manic phase of bipolar disorder, severe behavioral problems in children). Chlorpromazine helps the client to think more clearly, feel less nervous, and take part in everyday life. It can reduce aggressive behavior and the desire to hurt self/others. It may also help to decrease hallucinations (hearing/seeing things that are not there). Chlorpromazine is a psychiatric medication that belongs to the class of drugs called phenothiazine antipsychotics. It works by helping to restore the balance of certain natural substances in the brain. • Option B: Although the client may notice some medication effects soon after starting, for some conditions, it may take several weeks before they get the full benefit of this drug. Do not stop taking this medication without consulting a doctor. Some conditions may become worse when this drug is suddenly stopped. Also, the client may experience symptoms such as upset stomach, nausea, vomiting, dizziness, and shakiness. • Option C: If taking chlorpromazine to treat schizophrenia or another psychotic disorder, chlorpromazine may control the symptoms but will not cure the condition. Continue to take chlorpromazine even if feeling well. Do not stop taking chlorpromazine without talking to a doctor. The doctor will probably decrease the dose gradually. If the client suddenly stops taking chlorpromazine, they may experience withdrawal symptoms, such as nausea, vomiting, stomach pain, dizziness, and shakiness. 22. 22. Question A client is about to be discharged with a prescription for the antipsychotic agent haloperidol (Haldol), 10 mg by mouth twice per day. During a discharge teaching session, the nurse should provide which instruction to the client? • A. Take the medication 1 hour before a meal. • B. Decrease the dosage if signs of illness decrease. • C. Apply sunscreen before being exposed to the sun. • D. Increase the dosage up to 50 mg twice per day if signs of illness don’t decrease. Incorrect Correct Answer: C. Apply a sunscreen before being exposed to the sun. Because haloperidol can cause photosensitivity and precipitate severe sunburn, the nurse should instruct the client to apply a sunscreen before exposure to the sun. Photosensitivity is an adverse effect of many drugs, characteristically producing skin lesions in the areas exposed to light, which includes the face, “V” area of the neck, extensor surfaces of forearms, and dorsa of hands with sparing of submental and retroauricular areas. Two major mechanisms mediating drug induced photosensitivity reactions are phototoxic and photoallergic responses. • Option A: The nurse also should teach the client to take haloperidol with meals — not 1 hour before. Haloperidol is used widely in different countries. It is available in various forms; the oral route is the most common. For the oral administration, it is available as a tablet form and oral concentrate form. • Option B: The nurse should instruct the client not to decrease the dosage unless the physician orders it. Haloperidol is a first-generation (typical antipsychotic) which exerts its antipsychotic action by blocking dopamine D2 receptors in the brain. When 72% of dopamine receptors are blocked, this drug achieves its maximal effect. Haloperidol is not selective for the D2 receptor. It also has noradrenergic, cholinergic, and histaminergic blocking action. The blocking of these receptors is associated with various side effects. • Option D: Toxicities are the exaggerated symptoms of known pharmacologic effects and known adverse reactions. The most prominent toxicities of haloperidol are 1) severe extrapyramidal symptoms, hypotension, sedation. The patient may appear comatose with severe respiratory depression or shock from hypotension. The extrapyramidal symptoms are muscular weakness or rigidity, a generalized or localized tremor that may be characterized by the akinetic or agitation types of movements, respectively. Haloperidol overdose is also associated with ECG changes known as torsade de pointes, which may cause arrhythmia or cardiac arrest. 23. 23. Question A client with paranoid schizophrenia repeatedly uses profanity during an activity therapy session. Which response by the nurse would be most appropriate? • A. “Your behavior won’t be tolerated. Go to your room immediately.” • B. “You’re just doing this to get back at me for making you come to therapy.” • C. “Your cursing is interrupting the activity. Take time out in your room for 10 minutes.” • D. “I’m disappointed in you. You can’t control yourself even for a few minutes.” Incorrect Correct Answer: A. “Your behavior won’t be tolerated. Go to your room immediately.” The nurse should set limits on client behavior to ensure a comfortable environment for all clients. The nurse should accept hostile or quarrelsome client outbursts within limits without becoming personally offended. Maintain a consistent approach, employ consistent expectations, and provide a structured environment. Clear and consistent limits and expectations minimize the potential for client’s manipulation of staff. • Option B: This is incorrect because it implies that the client’s actions reflect feelings toward the staff instead of the client’s own misery. Remain neutral as possible; Do not argue with the client. The client can use inconsistencies and value judgments as justification for arguing and escalating mania. Use a calm and firm approach; provide structure and control for a client who is out of control. • Option C: Redirect agitation and potentially violent behaviors with physical outlets in an area of low stimulation (e.g., punching bag). This can help to relieve pent-up hostility and relieve muscle tension. Decrease environmental stimuli (e.g., by providing a calming environment or assigning a private room); helps decrease the escalation of anxiety and manic symptoms. • Option D: Judgmental remarks may decrease the client’s self-esteem. Use short, simple, and brief explanations or statements. A short attention span limits understanding to small pieces of information. Chart, in nurse’s notes, behaviors; interventions; what seemed to escalate agitation; what helped to calm agitation; when as-needed (PRN) medications were given and their effect; and what proved most helpful. 24. 24. Question Which of the following is one of the advantages of the newer antipsychotic medication risperidone (Risperdal)? • A. The absence of anticholinergic effects. • B. A lower incidence of extrapyramidal effects. • C. Photosensitivity and sedation. • D. No incidence of neuroleptic malignant syndrome. Incorrect Correct Answer: B. A lower incidence of extrapyramidal effects Risperdal has a lower incidence of extrapyramidal effects than the typical antipsychotics. SGAs have loose binding to D2 receptors and can quickly dissociate from the receptor, potentially accounting for the lower likelihood of causing extrapyramidal symptoms (EPS). Moreover, SGAs have agonism at the 5HT1A receptor. Serotonin and norepinephrine reuptake inhibition are potential mechanisms by which risperidone is postulated to produce antidepressant effects. The improvement of positive symptoms is thought to be accomplished through the blockade of D2 receptors specifically in the mesolimbic pathway. • Option A: Risperdal does produce anticholinergic effects and neuroleptic malignant syndrome can occur. Of note, risperidone does not cause anticholinergic effects, which may be of benefit for patients in certain populations including the elderly with dementia. • Option C: Photosensitivity isn’t an advantage. Although there are no mandatory requirements for therapeutic drug monitoring (TDM) with risperidone, monitoring plasma concentrations for this medication is strongly recommended by European guidelines because of data that shows interdependent variability. Therapeutic monitoring can be of benefit to assess compliance and in identifying low drug concentrations that may be low resulting in therapeutic failure. Also, monitoring the drug level can aid in evaluating for potential drug interactions and side effects. • Option D: Serious side effects of antipsychotic medications (like risperidone) can include neuroleptic malignant syndrome (NMS). Although the pathogenesis of NMS is not clear, it is a life-threatening condition that can manifest with altered mental status, fever, “lead pipe” rigidity, and autonomic instability including hypertension, tachypnea, and tachycardia. 25. 25. Question The etiology of schizophrenia is best described by: • A. Genetics due to a faulty dopamine receptor. • B. Environmental factors and poor parenting. • C. Structural and neurobiological factors. • D. A combination of biological, psychological, and environmental factors. Incorrect Correct Answer: D. A combination of biological, psychological, and environmental factors. A reliable genetic marker hasn’t been determined for schizophrenia. However, studies of twins and adopted siblings have strongly implicated a genetic predisposition. Since the mid-19th century, excessive dopamine activity in the brain has also been suggested as a causal factor. Communication and the family system have been studied as contributing factors in the development of schizophrenia. Therefore, a combination of biological, psychological, and environmental factors are thought to cause schizophrenia. • Option A: Several studies postulate that the development of schizophrenia results from abnormalities in multiple neurotransmitters, such as dopaminergic, serotonergic, and alpha-adrenergic hyperactivity or glutaminergic and GABA hypoactivity. Genetics also play a fundamental role – there is a 46% concordance rate in monozygotic twins and a 40% risk of developing schizophrenia if both parents are affected. The gene neuregulin (NGR1) which is involved in glutamate signaling and brain development has been implicated, alongside dysbindin (DTNBP1) which helps glutamate release, and catecholamine O-methyltransferase (COMT) polymorphism, which regulates dopamine function. • Option B: A viral infection, extensive exposure to toxins like marijuana, or highly stressful situations may trigger schizophrenia in people who have inherited a tendency to develop the disorder. It tends to surface when the body is undergoing hormonal and physical changes, such as during the teen and young adult years. • Option C: Twin studies suggest that at least some of these changes may result from other than genetic factors. Functional disturbances of the brain have also been connected with frontal and temporal structures in some schizophrenic patients. Of the single neurotransmitter substances, dopamine and serotonin appear to represent some of the central restitutive mechanisms whose function is to maintain mental stability; the understanding of their interplay with other neurotransmitters such as noradrenaline, acetylcholine, GABA, and glutamate, should provide a more integrated view of both normal and disturbed brain function. 26. 26. Question A client with schizophrenia who receives fluphenazine (Prolixin) develops pseudoparkinsonism and akinesia. What drug would the nurse administer to minimize extrapyramidal symptoms? • A. benztropine (Cogentin) • B. dantrolene (Dantrium) • C. clonazepam (Klonopin) • D. diazepam (Valium) Incorrect Correct Answer: A. benztropine (Cogentin) Benztropine is an anticholinergic drug administered to reduce extrapyramidal adverse effects in the client taking antipsychotic drugs. It works by restoring the equilibrium between the neurotransmitters acetylcholine and dopamine in the central nervous system (CNS). Thus, benztropine blocks the cholinergic muscarinic receptor in the central nervous system. Therefore, it reduces the cholinergic effects significantly during Parkinson’s disease which becomes more pronounced in the nigrostriatal tract because of reduced dopamine concentrations. • Option B: Dantrolene, a hydantoin drug that reduces the catabolic processes, is administered to alleviate the symptoms of neuroleptic malignant syndrome, a potentially fatal adverse effect of antipsychotic drugs. Dantrolene is used for the treatment of neuroleptic malignant syndrome (given its similarity in presentation and symptoms to malignant hyperthermia) as well as for the overdose of 2,4-dinitrophenol (a banned “fat burner” medication that interrupts ATP synthesis and causes hyperthermia). • Option C: Clonazepam, a benzodiazepine drug that depresses the CNS, is administered to control seizure activity. Clonazepam is a long-acting and high-potency benzodiazepine. It behaves both as a GABA-A receptor agonist and also as a serotonin agonist. Clonazepam has anticonvulsant and anxiolytic effects. It is FDA-approved for the treatment of seizure disorders and panic disorders. • Option D: Diazepam, a benzodiazepine drug, is administered to reduce anxiety. It is a fast-acting, long-lasting benzodiazepine commonly used in the treatment of anxiety disorders, as well as alcohol detoxification, acute recurrent seizures, severe muscle spasm, and spasticity associated with neurologic disorders. In the setting of acute alcohol withdrawal, diazepam is useful for symptomatic relief of agitation, tremor, alcoholic hallucinosis, and acute delirium tremens. 27. 27. Question A client with a diagnosis of paranoid schizophrenia comments to the nurse, “How do I know what is really in those pills?” Which of the following is the best response? • A. Say, “You know it’s your medicine.” • B. Allow him to open the individual wrappers of the medication. • C. Say, “Don’t worry about what is in the pills. It’s what is ordered.” • D. Ignore the comment because it’s probably a joke. Incorrect Correct Answer: B. Allow him to open the individual wrappers of the medication. This is correct because allowing a paranoid client to open his medication can help reduce suspiciousness. Talk openly with the client about their beliefs and thoughts, showing empathy and support. Help build trust and rapport with clients. Paranoid clients may be more reluctant to trust anyone, but open communication generally offers more cooperation. Explain all procedures clearly and carefully, and their purpose, before starting them. Prevents aggressive behavior and suspicion. Promotes cooperation and compliance. Helps develop trust. • Option A: This is incorrect because the client doesn’t know that it’s his medication and he’s obviously suspicious. Discuss feelings and help the client identify behaviors that cause conflict or alienate others. Helping clients see the reality of their behaviors can help treatment progress and lead to more appropriate behaviors and interactions. • Option C: Discuss and have the client demonstrate (through role-play if appropriate) more acceptable responses and reactions to behaviors and stressors. Helps the client develop more positive coping skills for dealing with delusions, suspicions, and fears. Provide reorientation as appropriate, but avoid confrontation of the delusions. The client may need to be refocused to reality at times, but avoid confrontation that may be interpreted as argumentative to avoid non-compliance and uncooperative behaviors. • Option D: Telling the client not to worry or ignoring the comment isn’t supportive and doesn’t offer reassurance. Set behavior boundaries and enforce per facility protocols with medications or restraints as necessary. Promote the safety of clients during agitated moments and the safety of others from aggressive behaviors. Follow your facility’s specific protocol regarding supervision, restraint, and documentation. 28. 28. Question A client tells the nurse that people from Mars are going to invade the earth. Which response by the nurse would be most therapeutic? • A. “That must be frightening to you. Can you tell me how you feel about it?” • B. “There are no people living on Mars.” • C. “What do you mean when you say they’re going to invade the earth?” • D. “I know you believe the earth is going to be invaded, but I don’t believe that.” Incorrect Correct Answer: A. “That must be frightening to