Exam (elaborations) NURS 1102 PASSPOINT PSYCHOTIC DISORDERS

NURS 1102 PASSPOINT PSYCHOTIC DISORDERS the psychiatric unit. A large group of reporters with cameras is camped out in the hospital parking lot. As a nurse walks to the employee parking after her shift, a reporter asks if she knows anything about the client's conditio Question 1 See full question A client with schizophrenia repeatedly uses profanity during an activity therapy session. Which response by the nurse is appropriate? You Selected:  "Your behavior won't be tolerated. Go to your room immediately." Correct response:  "Your cursing is interrupting the activity. Take time out in your room for 10 minutes." Explanation: Remediation: Question 2 See full question When conducting a mental status examination with a newly admitted client who has a diagnosis of paranoid schizophrenia, the client states, “I am being followed; it is not safe. They are monitoring my every move.” In which area of the mental status examination should the nurse document this information? You Selected:  insight Correct response:  thought content Explanation: Question 1 See full question A client with delusional thinking who is overweight and tends to eat when stressed shows a lack of interest in eating at meal times. She states that she is unworthy of eating and that her children will die if she eats. Which nursing action is most appropriate for this client? NURS 1102 PASSPOINT PSYCHOTIC DISORDERS You Selected:  Paying special attention to the client's meal-related rituals and emotions Correct response:  Restricting the client's access to food except at specified meal and snack times Explanation: Remediation: Question 2 See full question A client is about to be discharged with a prescription for the antipsychotic agent haloperidol, 10 mg by mouth twice per day. During a discharge teaching session, a nurse should provide which instruction to the client? You Selected:  Apply a sunscreen before exposure to the sun. Correct response:  Apply a sunscreen before exposure to the sun. Explanation: Remediation: Question 3 See full question A client has been receiving chlorpromazine, an antipsychotic, to treat his psychosis. Which findings should alert the nurse that the client is experiencing pseudoparkinsonism? You Selected:  Tremors, shuffling gait, and masklike face Correct response:  Tremors, shuffling gait, and masklike face Explanation: Remediation: Question 4 See full question Which response demonstrates that the parents of a child with newly diagnosed schizophrenia understand their child's diagnosis? You Selected:  "We'll watch him swallow his daily pills and call the physician if he doesn't." Correct response:  "We'll watch him swallow his daily pills and call the physician if he doesn't." Explanation: Remediation: Question 5 See full question During a home visit for a client diagnosed with paranoid schizophrenia discharged 1 week ago, the client’s mother tearfully states, “I can hardly sleep because I am so worried about my daughter. I am afraid to leave her alone in the house. What if something should happen while I am gone?” Which caregiver problem would be the most inclusive one for the nurse to incorporate into the client’s plan of care? You Selected:  disturbed sleep pattern Correct response:  caregiver role strain Explanation: Remediation: Question 6 See full question An outpatient client who has a history of paranoid schizophrenia and chronic alcohol dependency has been taking risperidone for several months. She reports that she stopped drinking 4 days ago. The client is very frightened by the tactile hallucinations of bugs crawling under her skin. Which factor should the nurse incorporate into the plan of care when explaining the tactile hallucinations? You Selected:  alcohol withdrawal Correct response:  alcohol withdrawal Explanation: Remediation: Question 7 See full question The client with a diagnosis of schizophrenia spends much of the morning in the bedroom but seeks out the nurse for brief interactions throughout the morning. Which goal should the nurse assist the client with achieving in the afternoon? The client will: You Selected:  engage three of his peers in a card game. Correct response:  help put a puzzle together. Explanation: Remediation: Question 8 See full question The client with a diagnosis of schizophrenia walks into group naked. The nurse should: You Selected:  lead the client to his room and help him dress if he needs assistance. Correct response:  lead the client to his room and help him dress if he needs assistance. Explanation: Remediation: Question 9 See full question One of the clients in group with a dual diagnosis of chronic schizophrenia and alcohol abuse states, “I am not going to take medicine every day.” Which response by the nurse would be mostappropriate? You Selected:  “I hear you say that you do not like taking medication daily.” Correct response:  “I hear you say that you do not like taking medication daily.” Explanation: Remediation: Question 10 See full question While planning the care for a client with paranoid delusions, which of the following will be the nurse’s initial goal for the client? You Selected:  Establish trust with staff. Correct response:  Establish trust with staff. Explanation: Remediation: Question 3 See full question One of the clients in group with a dual diagnosis of chronic schizophrenia and alcohol abuse states, “I am not going to take medicine every day.” Which response by the nurse would be mostappropriate? You Selected:  “Let us discuss this tomorrow if we have time.” Correct response:  “I hear you say that you do not like taking medication daily.” Explanation: Remediation: Question 4 See full question The client tells the nurse that she stopped taking olanzapine 2 weeks ago because she is better and wants “to make it on my own without this darned medicine.” What would be the nurse’s mosttherapeutic response? You Selected:  “You have told me about other times like this when you stopped taking your medication and you got sick again. You should know better by now.” Correct response:  ”I know you get tired of taking the medication, especially when you are doing well. Is there any special reason you decided to stop right now?” Explanation: Remediation: Question 5 See full question The guardian of a client diagnosed with schizophrenia indicates to the nurse a concern that the client is at risk for suicide. Which question to the client would the nurse utilize to determine the seriousness of the suicidal idealization? You Selected:  “Are you planning on hurting yourself?” Correct response: Question 1 See full question A client who takes neuroleptic medication for treatment of chronic schizophrenia is admitted to the psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, and diaphoresis. Which lifethreatening reaction do these findings suggest? You Selected:  Neuroleptic malignant syndrome Correct response:  Neuroleptic malignant syndrome Explanation: Remediation: Question 2 See full question A client with a diagnosis of borderline personality disorder is admitted to the psychiatric unit. The nurse expects the assessment to reveal: You Selected:  coldness, detachment, and lack of tender feelings. Correct response:  unpredictable behavior and intense interpersonal relationships. Explanation: A client with borderline personality disorder displays a pervasive pattern of unpredictable behavior, mood, and self-image. His interpersonal relationships may be intense and unstable, and his behavior may be inappropriate and impulsive. Although the client's impaired ability to form relationships may affect his parenting skills, his inability to function as a responsible parent is more typical of antisocial personality disorder. Somatic symptoms characterize avoidant personality disorder. Coldness, detachment, and lack of tender feelings typify schizoid and schizotypal personality disorders. Remediation: Question 3 See full question A client with a tentative diagnosis of psychosis is admitted to the psychiatric unit. A physician orders the phenothiazine thioridazine 50 mg by mouth three times per day. Phenothiazines differ from central nervous system (CNS) depressants in their sedative effects by producing: You Selected:  more prolonged sedative effects, making the client more difficult to arouse. Correct response:  a calming effect from which the client is easily aroused. Explanation: Remediation: Question 4 See full question A nurse is teaching a psychiatric client about his ordered drugs, chlorpromazine and benztropine. What evaluation would indicate a therapeutic response to these drugs? You Selected:  The client expresses a decrease in anxiety. Correct response:  The client is experiencing less psychosis and a decrease in extrapyramidal symptoms. Explanation: Benztropine is an anticholinergic medication administered to reduce the extrapyramidal adverse effects of chlorpromazine and other antipsychotic medications. Benztropine doesn't reduce psychotic symptoms, relieve anxiety, or control nausea and vomiting. If the client displays akathisia or meaningless movements, this is not a therapeutic effect of the medication. Remediation: Question 5 See full question The client with borderline personality disorder spends much time around the nurse's station, making numerous minor requests. The nurse interprets these behaviors as indicating which factor? You Selected:  fears of abandonment and attention seeking Correct response:  fears of abandonment and attention seeking Explanation: Remediation: Question 6 See full question A nurse is planning care for a regressed, chronically ill client diagnosed with schizophrenia. What is the most appropriate milieu? You Selected:  nurturance and supportive interaction focusing on individual needs Correct response:  nurturance and supportive interaction focusing on individual needs Explanation: Remediation: Question 1 See full question A client with schizophrenia is admitted to the psychiatric unit of a local hospital. During the next several days, the client is seen laughing, yelling, and talking to himself. This behavior is characteristic of: You Selected:  hallucination. Correct response:  hallucination. Explanation: Remediation: Question 2 See full question A well-known client suffers a psychotic break and is admitted to the psychiatric unit. A large group of reporters with cameras is camped out in the hospital parking lot. As a nurse walks to the employee parking after her shift, a reporter asks if she knows anything about the client's condition. What is the most appropriate response? You Selected:  "All I can say is that the client is safe and stable." Correct response:  "I can't answer your question." Explanation: Question 3 See full question Which response demonstrates that the parents of a child with newly diagnosed schizophrenia understand their child's diagnosis? You Selected:  "As long as we're understanding and supportive, he'll eventually be fine." Correct response:  "We'll watch him swallow his daily pills and call the physician if he doesn't." Explanation: Remediation: Question 4 See full question A nurse is planning care for a regressed, chronically ill client diagnosed with schizophrenia. What is the most appropriate milieu? You Selected:  nurturance and supportive interaction focusing on individual needs Correct response:  nurturance and supportive interaction focusing on individual needs Explanation: Remediation: Question 5 See full question During a home visit, a client who is 75 years of age tells the community health nurse, “Lately I am getting forgetful about things. For one thing, I cannot remember names. Do you think I am getting Alzheimer’s disease?” Which response by the nurse is the most therapeutic? You Selected:  “Most people your age have this problem. It is not Alzheimer’s disease.” Correct response:  “Tell me more about your forgetfulness. It is not unusual for forgetfulness to occur.” Explanation: A client with schizophrenia states, "I hear the voice of King Tut." Which response by the nurse is therapeutic? You Selected:  "I don't hear the voice, but I know you hear what sounds like a voice." Correct response:  "I don't hear the voice, but I know you hear what sounds like a voice." Explanation: Remediation: Question 2 See full question A client with a diagnosis of borderline personality disorder is admitted to the psychiatric unit. The nurse expects the assessment to reveal: You Selected:  unpredictable behavior and intense interpersonal relationships. Correct response:  unpredictable behavior and intense interpersonal relationships. Explanation: Remediation: Question 3 See full question A client begins clozapine therapy after several other antipsychotic agents fail to relieve her psychotic symptoms. The nurse instructs her to return for weekly white blood cell (WBC) counts to assess for which adverse reaction? You Selected:  Granulocytopenia Correct response:  Granulocytopenia Explanation: Remediation: Question 4 See full question While pacing in the hall, a client with schizophrenia runs to a nurse and asks, "Why are you poisoning me? I know you work for Central Thought Control! You can keep my thoughts. Give me back my soul!" How should the nurse respond during the early stage of the therapeutic process? You Selected:  "I'm a nurse, and you're a client in the hospital. I'm not going to harm you." Correct response:  "I'm a nurse, and you're a client in the hospital. I'm not going to harm you." Explanation: Remediation: Question 5 See full question A client diagnosed with borderline personality disorder has self-inflicted cuts on her arms. The nurse is assessing the client for the risk of suicide. What should the nurse ask the client first? You Selected:  if she has a suicide plan Correct response:  if she has a suicide plan Explanation: Remediation: Question 6 See full question A client diagnosed with schizophrenia is being switched to risperidone longacting injection. He is told that he will remain on his oral dose of risperidone daily for approximately 1 month. The client says, "I did not have to take pills when I was on fluphenazine shots in the past." The nurse should tell the client: You Selected:  "Risperidone long-acting injection initially takes a little longer to reach the ideal blood level." Correct response:  "Risperidone long-acting injection initially takes a little longer to reach the ideal blood level." Explanation: Remediation: Question 7 See full question A client has been perceiving her roommate's stuffed animal as her own dog at home. The nurse determines that this misperception of reality (illusion) is improving when the client makes which statement? You Selected:  "I wish Jan had not had my dog stuffed." Correct response:  "Jan's stuffed dog looks somewhat like my dog, Trixie." Explanation: Remediation: Question 8 See full question The director of an outpatient rehab program tells the nurse that the client with schizophrenia had done well for 6 months until last week, when a new person started the program. This new person worked faster than the client did and took his place as leader of the group. Based on this information, which intervention is most appropriate? You Selected:  Make an appointment to meet the client at the mental health center, and ask him about the situation. Correct response:  Make an appointment to meet the client at the mental health center, and ask him about the situation. Explanation: Remediation: Question 9 See full question Which intervention is essential when caring for a client who is experiencing delirium? You Selected:  identifying the underlying causative condition or illness Correct response:  identifying the underlying causative condition or illness Explanation: Remediation: Question 10 See full question A client tells the nurse, "Everybody smiles at me because they know that I was chosen by God for this mission." The nurse interprets this statement as which finding? You Selected:  visual hallucination Correct response:  idea of reference Explanation: Remediation: Question 11 See full question A health care provider prescribes haloperidol p.o. 1 mg t.i.d. When assessing the client for extrapyramidal adverse effects, which nursing measures would be initiated? Select all that apply. You Selected:  Observe for increased pacing and restlessness.  Closely monitor vital signs, especially temperature.  Monitor for signs and symptoms of urticaria. Correct response:  Closely monitor vital signs, especially temperature.  Observe for increased pacing and restlessness.  Provide the client with sugar free hard candy. Explanation: Remediation: Question 12 See full question The primary care provider prescribes risperidone 1 mg orally, two times a day for a client from a group home admitted to the hospital with severe antisocial behavior. The nurse determines that this dose is: You Selected:  Too low for the client. Correct response:  Typical when initiating therapy. Explanation: Remediation: Question 13 See full question A client comes to the mental health clinic 2 days after being discharged from the hospital. The client was given a 1-week supply of clozapine. Which client statement indicates an accurate understanding of the nurse's teaching about this medication? You Selected:  "I need to keep my appointment here at the clinic this week for a blood test." Correct response:  "I need to keep my appointment here at the clinic this week for a blood test." Explanation: Remediation: Question 14 See full question A client taking clozapine states, “I do not like feeling so sedated during the day. I can hardly keep my eyes open.” Which response by the nurse would be most appropriate? You Selected:  "Let us talk to your health care provider about taking most of the drug at bedtime.” Correct response:  "Let us talk to your health care provider about taking most of the drug at bedtime.” Explanation: Remediation: Question 15 See full question During a home visit, the nurse discovers that the client is less verbal, less active, less responsive to directions, severely anxious, and more stuporous. The nurse interprets these findings to indicate that the client needs which intervention? You Selected:  an increase in medication Correct response:  immediate medical evaluation Explanation: Remediation: Question 16 See full question The nurse is observing a client who is sitting alone in the day room and is intently focused on a nearby empty chair. Suddenly the client begins laughing hysterically and making frantic hand gestures at the chair. When the nurse approaches the client, he/she looks over at the chair, whispers something unintelligible, and shakes his/her head. How would the nurse best assess the client’s behavior in this situation? You Selected:  A hallucination Correct response: