Comprehensive Mental Health and Psychiatric Nursing NCLEX Practice Quiz #3: 75 Questions| 2022 update | RATED A+

Comprehensive Mental Health and Psychiatric Nursing NCLEX Practice Quiz #3: 75 Questions 1. 1. Question A psychotic client reports to the evening nurse that the day nurse put something suspicious in his water with his medication. The nurse replies, “You’re worried about your medication?” The nurse’s communication is: o A. An example of presenting reality o B. Reinforcing the client’s delusions o C. Focusing on emotional content o D. A non-therapeutic technique called mind-reading Incorrect Correct Answer: C. Focusing on emotional content The nurse should help the client focus on the emotional content rather than delusional material. Sometimes during a conversation, patients mention something particularly important. When this happens, nurses can focus on their statement, prompting patients to discuss it further. Patients don’t always have an objective perspective on what is relevant to their case; as impartial observers, nurses can more easily pick out the topics to focus on. • Option A: Presenting reality isn’t helpful because it can lead to confrontation and disengagement. It’s frequently useful for nurses to summarize what patients have said after the fact. This demonstrates to patients that the nurse was listening and allows the nurse to document conversations. Ending a summary with a phrase like “Does that sound correct?” gives patients explicit permission to make corrections if they’re necessary. • Option B: Agreeing with the client and supporting his beliefs are reinforcing delusions. Patients often ask nurses for advice about what they should do about particular problems or in specific situations. Nurses can ask patients what they think they should do, which encourages patients to be accountable for their own actions and helps them come up with solutions themselves. • Option D: Mind reading isn’t therapeutic. Similar to active listening, asking patients for clarification when they say something confusing or ambiguous is important. Saying something like “I’m not sure I understand. Can you explain it to me?” helps nurses ensure they understand what’s actually being said and can help patients process their ideas more thoroughly 2. 2. Question A client is admitted to the inpatient unit of the mental health center with a diagnosis of paranoid schizophrenia. He’s shouting that the government of France is trying to assassinate him. Which of the following responses is most appropriate? • A. “I think you’re wrong. France is a friendly country and an ally of the United States. Their government wouldn’t try to kill you.” • B. “I find it hard to believe that a foreign government or anyone else is trying to hurt you. You must feel frightened by this.” • C. “You’re wrong. Nobody is trying to kill you.” • D. “A foreign government is trying to kill you? Please tell me more about it.” Incorrect Correct Answer: B. “I find it hard to believe that a foreign government or anyone else is trying to hurt you. You must feel frightened by this.” Responses should focus on reality while acknowledging the client’s feelings. Sometimes during a conversation, patients mention something particularly important. When this happens, nurses can focus on their statement, prompting patients to discuss it further. Patients don’t always have an objective perspective on what is relevant to their case; as impartial observers, nurses can more easily pick out the topics to focus on. • Option A: Arguing with the client or denying his belief isn’t therapeutic. By using nonverbal and verbal cues such as nodding and saying “I see,” nurses can encourage patients to continue talking. Active listening involves showing interest in what patients have to say, acknowledging that you’re listening and understanding, and engaging with them throughout the conversation. Nurses can offer general leads such as “What happened next?” to guide the conversation or propel it forward. • Option C: Arguing can also inhibit development of a trusting relationship. Continuing to talk about delusions may aggravate the psychosis. It’s frequently useful for nurses to summarize what patients have said after the fact. This demonstrates to patients that the nurse was listening and allows the nurse to document conversations. Ending a summary with a phrase like “Does that sound correct?” gives patients explicit permission to make corrections if they’re necessary. • Option D: Asking the client if a foreign government is trying to kill him may increase his anxiety level and can reinforce his delusions. Voicing doubt can be a gentler way to call attention to the incorrect or delusional 3. 3. Question A client receiving haloperidol (Haldol) complains of a stiff jaw and difficulty swallowing. The nurse’s first action is to: • A. Reassure the client and administer as needed lorazepam (Ativan) I.M. • B. Administer as needed dose of benztropine (Cogentin) I.M. as ordered. • C. Administer as needed dose of benztropine (Cogentin) by mouth as ordered. • D. Administer as needed dose of haloperidol (Haldol) by mouth. Incorrect Correct Answer: B. Administer as needed dose of benztropine (Cogentin) I.M. as ordered. The client is most likely suffering from muscle rigidity due to haloperidol. I.M. benztropine should be administered to prevent asphyxia or aspiration. 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. • Option A: Lorazepam treats anxiety, not extrapyramidal effects. Lorazepam is a benzodiazepine medication developed by DJ Richards. It went on the market in the United States in 1977. Lorazepam has common use as the sedative and anxiolytic of choice in the inpatient setting owing to its fast (1 to 3 minute) onset of action when administered intravenously. Lorazepam is also one of the few sedative-hypnotics with a relatively clean side effect profile. Lorazepam is FDA approved for short-term (4 months) relief of anxiety symptoms related to anxiety disorders, anxiety-associated insomnia, anesthesia premedication in adults to relieve anxiety, or to produce sedation/amnesia, and treatment of status epilepticus. • Option C: Benztropine belongs to the synthetic class of muscarinic receptor antagonists (anticholinergic drugs). Thus, it has a structure similar to that of diphenhydramine and atropine. However, it is long-acting so that its administration can be with less frequency than diphenhydramine. It also induces less CNS stimulation effect compared to that of trihexyphenidyl, making it a preferable drug of choice for geriatric patients. • Option D: Another dose of haloperidol would increase the severity of the reaction. Since there is no specific antidote, supportive treatment is the mainstay of haloperidol toxicity. If a patient develops signs and symptoms of toxicities, the clinician should consider gastric lavage or induction of emesis as soon as possible, followed by the administration of activated charcoal. Maintenance of Airway, Breathing, and circulation are the most important factors for survival. 4. 4. Question The nurse is caring for a client with schizophrenia who experiences auditory hallucinations. The client appears to be listening to someone who isn’t visible. He gestures, shouts angrily, and stops shouting in mid-sentence. Which nursing intervention is the most appropriate? • A. Approach the client and touch him to get his attention. • B. Encourage the client to go to his room where he’ll experience fewer distractions. • C. Acknowledge that the client is hearing voices but make it clear that the nurse doesn’t hear these voices. • D. Ask the client to describe what the voices are saying. Incorrect Correct Answer: C. Acknowledge that the client is hearing voices but make it clear that the nurse doesn’t hear these voices. By acknowledging that the client hears voices, the nurse conveys acceptance of the client. By letting the client know that the nurse doesn’t hear the voices, the nurse avoids reinforcing the hallucination. Auditory hallucinations are the sensory perceptions of hearing voices without an external stimulus. This symptom is particularly associated with schizophrenia and related psychotic disorders but is not specific to it. Auditory hallucinations are one of the major symptoms of psychosis. • Option A: The nurse shouldn’t touch the client with schizophrenia without advance warning. The hallucinating client may believe that the touch is a threat or act of aggression and respond violently. • Option B: Being alone in his room encourages the client to withdraw and may promote more hallucinations. The nurse should provide an activity to distract the client. • Option D: By asking the client what the voices are saying, the nurse is reinforcing the hallucination. The nurse should focus on the client’s feelings, rather than the content of the hallucination. 5. 5. Question A client with paranoid schizophrenia has been experiencing auditory hallucinations for many years. One approach that has proven to be effective for hallucinating clients is to: • A. Take an as-needed dose of psychotropic medication whenever they hear voices. • B. Practice saying “Go away” or “Stop” when they hear voices. • C. Sing loudly to drown out the voices and provide a distraction. • D. Go to their room until the voices go away. Incorrect Correct Answer: B. Practice saying “Go away” or “Stop” when they hear voices. Researchers have found that some clients can learn to control bothersome hallucinations by telling the voices to go away or stop. The estimated prevalence of auditory hallucinations in the general population ranges from 5 to 28%. Auditory hallucinations are the most commonly reported in psychotic patients. They are prevalent in 75% of individuals suffering from schizophrenia, 20-50% of individuals with bipolar disorder, 10% of individuals with major psychotic depression, and 40% of individuals with PTSD. • Option A: Taking an as-needed dose of psychotropic medication whenever the voices arise may lead to overmedication and put the client at risk for adverse effects. Because the voices aren’t likely to go away permanently, the client must learn to deal with the hallucinations without relying on drugs. • Option C: Although distraction is helpful, singing loudly may upset other clients and would be socially unacceptable after the client is discharged. In children and adolescents, the prevalence has been noted to be 9% and ranging between 5 to 16%, respectively. In children, it is mostly seen in conjunction with conduct disorder, migraine, and anxiety. The discontinuation rate of auditory hallucinations in adolescence ranges from 3 to 40% each year. • Option D: Hallucinations are most bothersome in a quiet environment when the client is alone, so sending the client to his room would increase, rather than decrease, the hallucinations. Auditory hallucinatory experiences are psychopathological end-points. Disturbances in consciousness may occur earlier in the course that includes thought blocking, thought pressure, obsessive perseveration, and failure to discriminate between thought and perception. 6. 6. Question A client with catatonic schizophrenia is mute, can’t perform activities of daily living, and stares out the window for hours. What is the nurse’s first priority? • A. Assist the client with feeding • B. Assist the client with showering • C. Reassure the client about safety • D. Encourage socialization with peers Incorrect Correct Answer: A. Assist the client with feeding According to Maslow’s hierarchy of needs, the need for food is among the most important. The initial management includes supportive measures such as IV fluids and even nasogastric tubes given that patients with catatonia are susceptible to malnutrition, dehydration, pneumonia, etc. The key is early identification of catatonia in a patient with schizophrenia and initiation of treatment. • Option B: Catatonia again 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 C: Features of catatonia had been described since the 1800s with prominent physicians such as Kahlbaum and even Kraepelin, who defined catatonia within the larger definition of dementia praecox.[2] There are several theories behind the same as catatonia can be part of a larger psychiatric or neurological illness. Kahlbaum has ultimately been credited with the understanding that symptoms such as stupor and catalepsy were part of a larger syndrome of psychomotor abnormalities, which he termed as “catatonia.” This can be a part of a larger schizophrenic illness or even a bipolar affective illness or medical illness. • Option D: Other needs, in order of decreasing importance, include hygiene, safety, and a sense of belonging. The epidemiology of catatonic schizophrenia can be multivariate. It is said that about 10% of patients in psychiatric inpatient services have catatonic features.[7] On the one hand, the older school of psychiatry associated schizophrenia with catatonia, while newer epidemiological studies show that 20% of patients with catatonia have schizophrenia, and about 45% have symptoms of mood disorders and medical illness. 7. 7. Question A client tells the nurse that the television newscaster is sending a secret message to her. The nurse suspects the client is experiencing: • A. A delusion • B. Flight of ideas • C. Ideas of reference • D. Hallucination Incorrect Correct Answer: C. Ideas of reference Ideas of reference refers to the mistaken belief that neutral stimuli have special meaning to the individual such as the television newscaster sending a message directly to the individual. In people with bipolar disorder, mania and hypomania can comprise various symptoms, from reckless spending to sexual promiscuity. In addition, some more subtle symptoms may also occur, such as the belief held by some patients that everything occurring around them is related somehow to them when in fact it isn’t. This symptom is known as ideas of reference. • Option A: A delusion is a false belief. Delusions are defined as fixed, false beliefs that conflict with reality. Despite contrary evidence, a person in a delusional state can’t let go of their convictions. Delusions are often reinforced by the misinterpretation of events. Many delusions also involve some level of paranoia. For example, someone might contend that the government is controlling our every move via radio waves despite evidence to the contrary. • Option B: Flight of ideas is a speech pattern in which the client skips from one unrelated subject to another. A nearly continuous flow of accelerated speech with abrupt changes from topic to topic that are usually based on understandable associations, distracting stimuli, or plays on words. When severe, speech may be disorganized and incoherent. It is part of the DSM -5 criteria for Manic episodes. • Option D: A hallucination is a sensory perception, such as hearing voices and seeing objects, that only the client experiences. Hallucinations involve sensing things such as visions, sounds, or smells that seem real but are not. These things are created by the mind. Common hallucinations can include feeling sensations in the body, such as a crawling feeling on the skin or the movement of internal organs; hearing sounds, such as music, footsteps, windows or doors banging; hearing voices when no one has spoken (the most common type of hallucination). These voices may be positive, negative, or neutral. They may command someone to do something that may cause harm to themselves or others. 8. 8. Question The nurse knows that the physician has ordered the liquid form of the drug chlorpromazine (Thorazine) rather than the tablet form because the liquid: • A. Has a more predictable onset of action. • B. Produces fewer anticholinergic effects. • C. Produces fewer drug interactions. • D. Has a longer duration of action. Incorrect Correct Answer: A. Has a more predictable onset of action. A liquid phenothiazine preparation will produce effects in 2 to 4 hours. The onset of tablets is unpredictable. If your medicine comes in a dropper bottle, measure each dose with the special dropper provided with your prescription and dilute it in a small glass (4 ounces) of orange or grapefruit juice or water just before taking it. The dose medicines in this class will be different for different patients. Follow your doctor’s orders or the directions on the label. The following information includes only the average doses of these medicines. If your dose is different, do not change it unless your doctor tells you to do so. • Option B: Before using any prescription or over-the-counter (OTC) medicine for colds or allergies, check with your doctor. These medicines may increase the chance of developing heatstroke or other unwanted effects, such as dizziness, dry mouth, blurred vision, and constipation, while you are taking a phenothiazine. • Option C: Certain medicines should not be used at or around the time of eating food or eating certain types of food since interactions may occur. Using alcohol or tobacco with certain medicines may also cause interactions to occur. Discuss with your healthcare professional the use of your medicine with food, alcohol, or tobacco. • Option D: The amount of medicine that you take depends on the strength of the medicine. Also, the number of doses you take each day, the time allowed between doses, and the length of time you take the medicine depend on the medical problem for which you are using the medicine. 9. 9. Question A client who has been hospitalized with disorganized type schizophrenia for 8 years can’t complete activities of daily living (ADLs) without staff direction and assistance. The nurse formulates a nursing diagnosis of Self-care deficit: Dressing/grooming related to inability to function without assistance. What is an appropriate goal for this client? • A. “Client will be able to complete ADLs independently within 1 month.” • B. “Client will be able to complete ADLs with only verbal encouragement within 1 month.” • C. “Client will be able to complete ADLs with assistance in organizing grooming items and clothing within 1 month.” • D. “Client will be able to complete ADLs with complete assistance within 1 month.” Incorrect Correct Answer: C. “Client will be able to complete ADLs with assistance in organizing grooming items and clothing within 1 month.” The client’s disorganized personality and history of hospitalization have affected the ability to perform self-care activities. Disorganized schizophrenia is one of the five subtypes of schizophrenia. It is characterized by disorganized behavior and speech and includes disturbance in emotional expression. Hallucinations and delusions are less pronounced with disorganized schizophrenia, though there is evidence of these symptoms occurring. • Option A: Interventions should be directed at helping the client complete ADLs with the assistance of staff members, who can provide needed structure by helping the client select grooming items and clothing. This goal promotes realistic independence. Assistance with life skills can help individuals with disorganized schizophrenia improve social interactions and increase daily living skills, with a goal of increasing independence. • Option B: As the client improves and achieves the established goal, the nurse can set new goals that focus on the client completing ADLs with only verbal encouragement and, ultimately, completing them independently. Individuals with disorganized schizophrenia benefit from ongoing contact with the family. Support to educate the family about treatment and how to support a family member with schizophrenia is crucial. Family support increases family member’s understanding of the disorder and helps family members develop coping strategies. • Option D: The client’s condition doesn’t indicate a need for complete assistance, which would only foster dependence. Assistance with daily living skills, educational attainment, employment services, and family support plays a key role in improving the course of the disease for individuals diagnosed with disorganized schizophrenia. 10. 10. Question The nurse is planning care for a client admitted to the psychiatric unit with a diagnosis of paranoid schizophrenia. Which nursing diagnosis should receive the highest priority? • A. Risk for violence toward self or others • B. Imbalanced nutrition: Less than body requirements • C. Ineffective family coping • D. Impaired verbal communication Incorrect Correct Answer: A. Risk for violence toward self or others Because of such factors as suspiciousness, anxiety, and hallucinations, the client with paranoid schizophrenia is at risk for violence toward himself or others. 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. • Option B: The positive symptoms of schizophrenia—things like hallucinations and delusions—are less likely to go unnoticed. After the prodromal phase, the patient enters the active phase of schizophrenia, during which they experience debilitating thoughts and perceptual distortions. They may experience impaired motor or cognitive functions, including disorganized speech and disorganized or catatonic behavior. • Option C: Early symptoms of schizophrenia may seem rather ordinary and could be explained by a number of other factors. This includes socializing less often with friends, trouble sleeping, irritability, or a drop in grades. During the onset of schizophrenia — otherwise known as the prodromal phase — negative symptoms mount. These negative symptoms might include an increasing lack of motivation, decreasing inability to pay attention or social isolation. • Option D: The paranoia in paranoid schizophrenia stems from delusions—firmly held beliefs that persist despite evidence to the contrary — and hallucinations — seeing or hearing things that others do not. Both of these experiences can be persecutory or threatening in nature. A patient may hear a voice or voices in their head that they do not recognize as their own thoughts or internal voice. These voices can be demeaning or hostile, driving a person to do things they would not do otherwise. 11. 11. Question The nurse is preparing for the discharge of a client who has been hospitalized for paranoid schizophrenia. The client’s husband expresses concern over whether his wife will continue to take her daily prescribed medication. The nurse should inform him that: • A. His concern is valid but his wife is an adult and has the right to make her own decisions. • B. He can easily mix the medication in his wife’s food if she stops taking it. • C. His wife can be given a long-acting medication that is administered every 1 to 4 weeks. • D. His wife knows she must take her medication as prescribed to avoid future hospitalizations. Incorrect Correct Answer: C. His wife can be given a long-acting medication that is administered every 1 to 4 weeks. Long-acting psychotropic drugs can be administered by depot injection every 1 to 4 weeks. These agents are useful for noncompliant clients because the client receives the injection at the outpatient clinic. When schizophrenia is diagnosed, antipsychotic medication is most typically prescribed. This can be given as a pill, a patch, or an injection. There are long-term injections that have been developed which could eliminate the problems of a patient not regularly taking their medication (called “medication noncompliance”). • Option A: A client has the right to refuse medication, but this issue isn’t the focus of discussion at this time. Someone with schizophrenia may not recognize that their behavior, hallucinations, or delusions are unusual or unfounded. This can cause a person to stop taking antipsychotic medication, stop participating in therapy, or both, which can result in a relapse into active phase psychosis. • Option B: Medication should never be hidden in food or drink to trick the client into taking it; besides destroying the client’s trust, doing so would place the client at risk for overmedication or under medication because the amount administered is hard to determine. While antipsychotic medication is effective in treating the positive symptoms of schizophrenia, it does not address negative symptoms.8 In addition, these drugs can have unwanted side effects including weight gain, drowsiness, restlessness, nausea, vomiting, low blood pressure, dry mouth, and lowered white blood cell count. • Option D: Assuming the client knows she must take the medication to avoid future hospitalizations would be unrealistic. Psychotherapy also plays an important role in the treatment of schizophrenia. Cognitive-behavioral therapy has been shown to help patients develop and retain social skills, alleviate comorbid anxiety and depression symptoms, cope with trauma in their past, improve relationships with family and friends, and support occupational recovery. 12. 12. Question Benztropine (Cogentin) is used to treat the extrapyramidal effects induced by antipsychotics. This drug exerts its effect by: • A. Decreasing the anxiety causing muscle rigidity. • B. Blocking the cholinergic activity in the central nervous system (CNS). • C. Increasing the level of acetylcholine in the CNS. • D. Increasing norepinephrine in the CNS. Incorrect Correct Answer: B. Blocking the cholinergic activity in the central nervous system (CNS). This is the action of Cogentin. Benztropine antagonizes acetylcholine and histamine receptors. In the CNS and smooth muscles, benztropine exerts its action through competing with acetylcholine at muscarinic receptors. Consequently, it reduces central cholinergic effects by blocking muscarinic receptors that appear to improve the symptoms of Parkinson disease. Thus, benztropine blocks the cholinergic muscarinic receptor in the central nervous system. Therefore, it reduces the cholinergic effects significantly during Parkinson disease which becomes more pronounced in the nigrostriatal tract because of reduced dopamine concentrations. • Option A: Anxiety doesn’t cause extrapyramidal effects. Benztropine belongs to the synthetic class of muscarinic receptor antagonists (anticholinergic drug). Thus, it has a structure similar to that of diphenhydramine and atropine. However, it is long-acting so that its administration can be with less frequency than diphenhydramine. It also induces less CNS stimulation effect compared to that of trihexyphenidyl, making it a preferable drug of choice for geriatric patients. • Option C: Overactivity of acetylcholine and lower levels of dopamine are the causes of extrapyramidal effects. It is also useful for drug-induced extrapyramidal symptoms and the prevention of dystonic reactions and acute treatment of dystonic reactions. Furthermore, benztropine has further off-label use as it can treat chronic sialorrhea occurring in developmentally-disabled patients. Also, several clinical studies worked on using benztropine in managing intractable hiccups. • Option D: Benztropine doesn’t increase norepinephrine in the CNS. Benztropine overdose can cause an anticholinergic toxidrome, which, in its role, may require supportive care. Commonly, the risk assessment for benztropine overdose can take place as soon as 6 hours after overdose ingestion, and toxicity effects may last variably between 12 hours to 5 days at most. The most crucial step of proper detection of benztropine overdose starts from carrying out intensive and inclusive investigations. For example, ECG can be an essential assessment tool using 12 leads during testing. Also, monitoring the acetaminophen concentrations as well as blood glucose concentrations can become a useful method for toxicity investigations if the toxicant is unknown. 13. 13. Question A dopamine receptor agonist such as bromocriptine (Parlodel) relieves muscle rigidity caused by antipsychotic medication by: • A. Blocking dopamine receptors in the central nervous system (CNS) • B. Blocking acetylcholine in the CNS • C. Activating norepinephrine in the CNS • D. Activating dopamine receptors in the CNS Incorrect Correct Answer: D. Activating dopamine receptors in the CNS Extrapyramidal effects and the muscle rigidity induced by antipsychotic medications are caused by a low level of dopamine. In groups of patients with Parkinson’s disease where levodopa is no longer as effective, co-administration with dopamine agonists such as bromocriptine historically was a successful option. Further, bromocriptine is also used as an early treatment for PD to delay the onset of the use of levodopa, ultimately delaying the likely dyskinesia and motor fluctuations that occur with chronic use. • Option A: Dopamine receptor agonists stimulate dopamine receptors and thereby reduce rigidity. Bromocriptine is a dopamine receptor agonist that has selective agonist activity on D2 dopamine receptors while simultaneously acting as a partial antagonist for D1 dopamine receptors.[12] Dopamine agonism has variable effects depending on the target tissue. In Parkinson disease, bromocriptine binds directly to striatal dopamine D2 receptors, stimulating locomotion and attenuating the bradykinetic symptoms caused by the degeneration of dopaminergic nigrostriatal neurons. • Option B: Parkinson disease (PD) is a progressive neurological disorder characterized by resting tremor, rigidity, akinesia or bradykinesia, and postural instability due to the loss of dopaminergic neurons in the substantia nigra. Although levodopa is an effective treatment of PD, with chronic use, there is a decline in efficacy and motor complications. • Option C: They don’t affect norepinephrine or acetylcholine. Bromocriptine is a medication currently used in the management and treatment of Type II diabetes mellitus. It is an ergot alkaloid derivative in the dopamine D2 agonist class of drugs. This discussion reviews the indications, contraindications, and mechanism of action for bromocriptine as a valuable agent in the management for Type II diabetes mellitus, as well as its more traditional uses in Parkinson’s disease, acromegaly, and pituitary prolactinomas. 14. 14. Question Most antipsychotic medications exert the following effects on the central nervous system (CNS)? • A. Stimulates the CNS by blocking postsynaptic dopamine, norepinephrine, and serotonin receptors. • B. Sedate the CNS by stimulating serotonin at the synaptic cleft. • C. Depress the CNS by blocking the postsynaptic transmission of dopamine, serotonin, and norepinephrine. • D. Depress the CNS by stimulating the release of acetylcholine. Incorrect Correct Answer: C. Depress the CNS by blocking the postsynaptic transmission of dopamine, serotonin, and norepinephrine. The exact mechanism of antipsychotic medication action is unknown, but appears to depress the CNS by blocking the transmission of three neurotransmitters: dopamine, serotonin, and norepinephrine. The first-generation antipsychotics work by inhibiting dopaminergic neurotransmission. Their effectiveness is best when they block about 72% of the D2 dopamine receptors in the brain. They also have noradrenergic, cholinergic, and histaminergic blocking action. • Option A: Second-generation antipsychotics work by blocking D2 dopamine receptors as well as serotonin receptor antagonist action. the 5-HT2A subtype of serotonin receptor is most commonly involved. Second-generation antipsychotics are serotonin-dopamine antagonists and are also known as atypical antipsychotics. The Food and Drug Administration (FDA) has approved 12 atypical antipsychotics as of the year 2016. They are risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, paliperidone, asenapine, lurasidone, iloperidone, cariprazine, brexpiprazole, and clozapine. • Option B: First and second-generation antipsychotics (except clozapine) are indicated for the treatment of an acute episode of psychoses as well as maintenance therapy of schizophrenia and schizoaffective disorders. First-generation antipsychotics are better for treating positive symptoms of schizophrenia, e.g., hallucinations, delusions, among others. They also decrease the risk of a repeat episode of psychosis. Second-generation antipsychotics treat both positive symptoms and negative symptoms of schizophrenia, e.g., withdrawal, ambivalence, among others, and are known to reduce relapse rates. • Option D: They don’t sedate the CNS by stimulating serotonin, and they don’t stimulate neurotransmitter action or acetylcholine release. First-generation antipsychotics are effective in the treatment of acute mania with psychotic symptoms. All second-generation antipsychotics except clozapine can also be used as a treatment of symptoms of acute mania. Antipsychotics are used with mood stabilizers like lithium, valproic acid, or carbamazepine initially, and then after symptoms stabilize can be gradually decreased and withdrawn. 15. 15. Question A client is admitted to the psychiatric unit of a local hospital with chronic undifferentiated schizophrenia. During the next several days, the client is seen laughing, yelling, and talking to herself. This behavior is characteristic of: • A. Delusion • B. Looseness of association • C. Illusion • D. Hallucination Incorrect Correct Answer: D. Hallucination Auditory hallucination, in which one hears voices when no external stimuli exist, is common in schizophrenic clients. Such behaviors as laughing, yelling, and talking to oneself suggest such a hallucination. Auditory hallucinations are the sensory perceptions of hearing voices without an external stimulus. This symptom is particularly associated with schizophrenia and related psychotic disorders but is not specific to it. Auditory hallucinations are one of the major symptoms of psychosis. • Option A: Delusions, also common in schizophrenia, are false beliefs or ideas that arise without external stimuli. Jaspers () was amongst the first to describe and classify delusions. In his book General Psychopathology (1913), he suggests that a delusion is a “perverted view of reality, incorrigibly held.” These perversions are enigmatically derived, held with extraordinary certainty, and absolutely unamenable. He further emphasized that these false beliefs exist along a continuum of thought disturbance, increasing in severity of distortion from normal thinking patterns to ‘true’ delusions. One hundred years later, Jaspers’ postulation remains a leading candidate in the investigation of delusion morphology. • Option B: Clients with schizophrenia may exhibit looseness of association, a pattern of thinking and communicating in which ideas aren’t clearly linked to one another. A thought disturbance demonstrated by speech that is disconnected and fragmented, with the individual jumping from one idea to another unrelated or indirectly related idea. It is essentially equivalent to derailment. • Option C: Illusion is a less severe perceptual disturbance in which the client misinterprets actual external stimuli. Illusions are rarely associated with schizophrenia. Illusion, a misrepresentation of a “real” sensory stimulus—that is, an interpretation that contradicts objective “reality” as defined by general agreement. For example, a child who perceives tree branches at night as if they are goblins may be said to be having an illusion. 16. 16. Question Which of the following medications would the nurse expect the physician to order to reverse a dystonic reaction? • A. prochlorperazine (Compazine) • B. diphenhydramine (Benadryl) • C. haloperidol (Haldol) • D. midazolam (Versed) Incorrect Correct Answer: B. diphenhydramine (Benadryl) Diphenhydramine, 25 to 50 mg I.M. or I.V., would quickly reverse this condition. An acute dystonic reaction is characterized by involuntary contractions of muscles of the extremities, face, neck, abdomen, pelvis, or larynx in either sustained or intermittent patterns that lead to abnormal movements or postures. The symptoms may be reversible or irreversible and can occur after taking any dopamine receptor-blocking agents. Treatment of acute dystonic reaction centers around balancing the disrupted dopaminergic-cholinergic balance in the basal ganglia and discontinuation of the offending agent. The most commonly available drugs in the emergency setting for the treatment of acute dystonic reaction are diphenhydramine and benztropine. • Option A: Prochlorperazine can be used to treat both acute psychotic episodes and chronic mental illnesses. As a first-generation antipsychotic, the drug is better at treating positive symptoms than negative ones, including delusions, hallucinations, agitation, and disorganized speech and behavior. • Option C: Haloperidol is capable of causing dystonia, not reversing it. Due to the blockade of the dopamine pathway in the brain, typical antipsychotic medications such as haloperidol have correlations with extrapyramidal side effects. 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. • Option D: Midazolam would make this client drowsy. Midazolam can be used for anxiolysis and hypnosis during the maintenance phase of general anesthesia and is also superior to thiopental in the maintenance of anesthesia because of the less need for adjunct medications. Midazolam is used as an adjunct medication to regional and local anesthesia for a wide range of diagnostic and therapeutic procedures and has greater patient and physician acceptance. 17. 17. Question A schizophrenic client states, “I hear the voice of King Tut.” Which response by the nurse would be most therapeutic? • A. “I don’t hear the voice, but I know you hear what sounds like a voice.” • B. “You shouldn’t focus on that voice.” • C. “Don’t worry about the voice as long as it doesn’t belong to anyone real.” • D. “King Tut has been dead for years.” Incorrect Correct Answer: A. “I don’t hear the voice, but I know you hear what sounds like a voice.” This response states reality about the client’s hallucination. Voicing doubt can be a gentler way to call attention to the incorrect or delusional ideas and perceptions of patients. By expressing doubt, nurses can force patients to examine their assumptions. • Option B: Sometimes during a conversation, patients mention something particularly important. When this happens, nurses can focus on their statement, prompting patients to discuss it further. Patients don’t always have an objective perspective on what is relevant to their case; as impartial observers, nurses can more easily pick out the topics to focus on. • Option C: For patients experiencing sensory issues or hallucinations, it can be helpful to ask about them in an encouraging, non-judgmental way. Phrases like “What do you hear now?” or “What does that look like to you?” give patients a prompt to explain what they’re perceiving without casting their perceptions in a negative light. • Option D: The other options are judgmental, flippant, or dismissive. Similar to active listening, asking patients for clarification when they say something confusing or ambiguous is important. Saying something like “I’m not sure I understand. Can you explain it to me?” helps nurses ensure they understand what’s actually being said and can help patients process their ideas more thoroughly. 18. 18. Question A client has been receiving chlorpromazine (Thorazine), an antipsychotic, to treat his psychosis. Which findings should alert the nurse that the client is experiencing pseudoparkinsonism? • A. Restlessness, difficulty sitting still, and pacing • B. Involuntary rolling of the eyes • C. Tremors, shuffling gait, and masklike face • D. Extremity and neck spasms, facial grimacing, and jerky movements Incorrect Correct Answer: C. Tremors, shuffling gait, and mask-like face Pseudoparkinsonism may appear 1 to 5 days after starting an antipsychotic and may also include drooling, rigidity, and “pill-rolling.” Despite being a low-potency drug, chlorpromazine can still cause extrapyramidal side effects (EPS) such as acute dystonia, akathisia, parkinsonism, and tardive dyskinesia (TD). The evolution of EPS side effects can occur through hours to days. Acute dystonia refers to muscle stiffness or spasm of the head, neck, and eye muscles that can start hours after starting the medication. Akathisia includes restlessness and fast pacing. Parkinsonism includes bradykinesia, “cogwheel” rigidity, and shuffling gait. • Option A: Akathisia may occur several weeks after starting antipsychotic therapy and consists of restlessness, difficulty sitting still, and fidgeting. Patients are at risk of developing neuroleptic malignant syndrome (NMS), which is a life-threatening manifestation, where the patient presents with “lead-pipe” muscle rigidity, autonomous instability, hyperpyrexia more than 40 degrees Celsius, altered mental status, leukocytosis, and elevated serum creatinine kinase. • Option B: An oculogyric crisis is recognized by uncontrollable rolling back of the eyes and, along with dystonia, should be considered an emergency. Chlorpromazine use also requires caution in patients with cerebrovascular and cardiovascular diseases. Patients should start on a low dose of chlorpromazine as an initial dosage, and the increase in subsequent dosing should be gradual. However, treatment should be discontinued if the patient develops agranulocytosis. • Option D: Dystonia may occur minutes to hours after receiving an antipsychotic and may include extremity and neck spasms, jerky muscle movements, and facial grimacing. Chlorpromazine belongs to the category of typical antipsychotics or neuroleptics, also known as first-generation antipsychotics (FGAs). It produces its antipsychotic effect by the post-synaptic blockade at the D2 receptors in the mesolimbic pathway. However, the blockade of D2 receptors in the nigrostriatal pathway is responsible for its extrapyramidal side effects. 19. 19. Question For several years, a client with chronic schizophrenia has received 10 mg of fluphenazine hydrochloride (Prolixin) by mouth four times per day. Now the client has a temperature of 102° F (38.9° C), a heart rate of 120 beats/minute, a respiratory rate of 20 breaths/minute, and a blood pressure of 210/140 mm Hg. Because the client also is confused and incontinent, the nurse suspects malignant neuroleptic syndrome. What steps should the nurse take? • A. Give the next dose of fluphenazine, call the physician, and monitor vital signs. • B. Withhold the next dose of fluphenazine, call the physician, and monitor vital signs. • C. Give the next dose of fluphenazine and restrict the client to the room to decrease stimulation. • D. Withhold the next dose of fluphenazine, administer an antipyretic agent, and increase the client’s fluid intake. Incorrect Correct Answer: B. Withhold the next dose of fluphenazine, call the physician, and monitor vital signs. Malignant neuroleptic syndrome is a dangerous adverse effect of neuroleptic drugs such as fluphenazine. Although an antipyretic agent may be used to reduce fever, increased fluid intake is contraindicated because it may increase the client’s fluid volume further, raising blood pressure even higher. Rare but serious side effects include neuroleptic malignant syndrome, liver function abnormalities and jaundice, seizures, and agranulocytosis. Like other antipsychotic medications, fluphenazine carries a black-box warning for increased risk of cerebrovascular events and death in elderly patients with psychosis related to major neurocognitive disorder. There are reports of allergic reactions with the use of fluphenazine and other phenothiazine typical antipsychotics. • Option A: Patients taking any antipsychotic medication require close monitoring for the appearance of side effects. Baseline electrocardiograms should be obtained in all patients with preexisting cardiac conduction abnormalities starting fluphenazine; close monitoring for electrocardiogram changes is necessary. Assessments for the appearance of extrapyramidal side effects should be routine for patients taking fluphenazine; the Abnormal Involuntary Movement Scale is a well-studied, easy-to-administer assessment for the emergence of extrapyramidal effects. • Option C: Clinicians should routinely obtain complete blood counts and metabolic panels to monitor for changes in white blood cell counts, liver transaminases, and blood urea nitrogen and creatinine levels. Patients taking multiple medications also require monitoring for interactions with fluphenazine; this medication is a major substrate of the CYP-2D6 system and is a weak inhibitor of CYP-2C9 and CYP-2E1 systems. Although serum levels of fluphenazine are not a routine part of therapy and dosing typically depends on clinical response, the therapeutic reference range is 1 nanogram to 10 nanograms per milliliter. • Option D: Fluphenazine has an adverse effect profile similar to other first-generation or typical antipsychotics, which is due to its dopamine receptor antagonism as well as its anticholinergic, antihistaminic, and alpha-adrenergic antagonistic properties. Common side effects include sedation, dry mouth, constipation, dry eyes, blurred vision, constipation, orthostasis, dizziness, hypotension, and urinary retention. Other possible side effects include rebound tachycardia, urinary retention, and weight gain. Due to dopaminergic antagonism, fluphenazine can cause extrapyramidal symptoms, including akathisia, parkinsonian features such as resting tremor and shuffling gait, acute dystonic reactions, oculogyric crises, opisthotonos, and tardive dyskinesia. 20. 20. Question A schizophrenic client with delusions tells the nurse, “There is a man wearing a red coat who’s out to get me.” The client exhibits increasing anxiety when focusing on the delusions. Which of the following would be the best response? • A. “This subject seems to be troubling you. Let’s walk to the activity room.” • B. “Describe the man who’s out to get you. What does he look like?” • C. “There is no reason to be afraid of that man. This hospital is very secure.” • D. “There is no need to be concerned with a man who isn’t even real.” Incorrect Correct Answer: A. “This subject seems to be troubling you. Let’s walk to the activity room.” This remark distracts the client from the delusion by engaging the client in a less threatening or more comforting activity at the first sign of anxiety. The nurse should reinforce reality and discourage the false belief. As a nursing diagnosis in the presence of delusions, the Nursing Interventions Classification (NIC) defines Delusion Control (6440), which is defined as the provision of a safe and therapeutic environment to the patient in acute state of confusion.2 Thus, in the presence of delusions, the nurses must demonstrate to patients that they accept that the patient has this belief, although they do not share the belief. • Option B: It is important not to discuss or deny belief so as not to risk compromising trust. Reasonable doubt must therefore be used as a therapeutic technique. For example, “I understand that you believe this to be true, but I do not think the same.” • Option C: One should also reinforce reality and talk about things and people that are real, avoiding ruminant thinking in false beliefs. The nurse should also be attentive during feeding and taking medication, since the delirium of poisoning may be present and the patient may believe that the food or medication is to poison him. Thus, it may be necessary to confirm whether the patient has taken the medication. • Option D: The other options focus on the content of the delusion rather than the meaning, feeling, or intent that it provokes. Establishing a therapeutic relationship is not easy, requiring special attention on the part of the nurse. Active listening and empathy are especially important and should focus on the patient’s experiences. Authenticity is necessary, allowing the person to distinguish between what is part of the disease and what is not part of it, i.e., what is real and what is not. It is crucial to help the patient find their personal resources and identify achievable goals in the medium and long term and the means to achieve them. 21. 21. Question Important teaching for women in their childbearing years who are receiving antipsychotic medications includes which of the following? • A. Occurrence of increased libido due to medication adverse effects. • B. Increased incidence of dysmenorrhea while taking the drug. • C. Continuing previous use of contraception during periods of amenorrhea. • D. Instruction that amenorrhea is irreversible. Incorrect Correct Answer: C. Continuing previous use of contraception during periods of amenorrhea Women may experience amenorrhea, which is reversible, while taking antipsychotics. Amenorrhea doesn’t indicate cessation of ovulation; therefore, the client can still become pregnant. The client should be instructed to continue contraceptive use even when experiencing amenorrhea. • Option A: Libido generally decreases because of the depressant effect. Although women with serious mental illness have high rates of lifetime sexual partners, they infrequently use contraception. Consequently, the prevalence of sexually transmitted infections is high in this population. In addition, while the overall rate of pregnancy in women with schizophrenia of child-bearing age is lower than in the general population, the percentage of pregnancies that are unwanted is higher than that in the general population. • Option B: Dysmenorrhea isn’t an adverse effect of antipsychotics. Contraceptive counseling to women and their partners is an important part of comprehensive care for women with serious and persistent mental illness. Women with schizophrenia who smoke, are overweight, or have diabetes, migraine, cardiovascular disease, or a family history of breast cancer should be offered non-hormonal contraception. Women with more than one sexual partner should be advised on barrier methods in addition to any other contraceptive measures they are using. • Option D: Amenorrhea is reversible, so the woman could still become pregnant. Contraceptive counseling to women and their partners is an important part of comprehensive care for women with serious and persistent mental illness. Women with schizophrenia who smoke, are overweight, or have diabetes, migraine, cardiovascular disease, or a family history of breast cancer should be offered non-hormonal contraception. Women with more than one sexual partner should be advised on barrier methods in addition to any other contraceptive measures they are using. 22. 22. Question A client is admitted to a psychiatric facility with a diagnosis of chronic schizophrenia. The history indicates that the client has been taking neuroleptic medication for many years. Assessment reveals unusual movements of the tongue, neck, and arms. Which condition should the nurse suspect? • A. Tardive dyskinesia • B. Dystonia • C. Neuroleptic malignant syndrome • D. Akathisia Incorrect Correct Answer: A. Tardive dyskinesia Unusual movements of the tongue, neck, and arms suggest tardive dyskinesia, an adverse reaction to neuroleptic medication. Tardive dyskinesia (TD) is a syndrome which includes a group of iatrogenic movement disorders caused due to a blockade of dopamine receptors. The movement disorders include akathisia, dystonia, buccolingual stereotypy, myoclonus, chorea, tics and other abnormal involuntary movements which are commonly caused by the long-term use of typical antipsychotics. TD is most common in schizophrenics and bipolar patients treated with antipsychotic medications, but they can occur in any patients. In addition, these medications can also induce parkinsonian syndromes. Research reveals that there is a dysfunction of the dopamine transporter that leads to TD. • Option B: Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles. Dystonia is defined by involuntary maintained contraction of agonist and antagonist muscles yielding abnormal posturing, twisting and repetitive movements, or tremulous and can be initiated or worsened by attempted movement. Dystonia is a dynamic disorder that changes in severity based on the activity and posture. Dystonia may assume a pattern of overextension or over-flexion of the hand, inversion of the foot, lateral flexion or retroflection of the head, torsion of the spine with arching and twisting of the back, forceful closure of the eyes, or a fixed grimace. It may come to an end when the body is in action and during sleep. • Option C: Neuroleptic malignant syndrome causes rigidity, fever, hypertension, and diaphoresis. Neuroleptic malignant syndrome (NMS) is a life-threatening syndrome associated with the use of dopamine-receptor antagonist medications or with rapid withdrawal of dopaminergic medications. NMS has been associated with virtually every neuroleptic agent but is more commonly reported with the typical antipsychotics like haloperidol and fluphenazine. Classic clinical characteristics include mental status changes, fever, muscle rigidity, and autonomic instability. • Option D: Akathisia causes restlessness, anxiety, and jitteriness. Akathisia is defined as an inability to remain still. It is a neuropsychiatric syndrome that is associated with psychomotor restlessness. The individual with akathisia will generally experience an intense sensation of unease or an inner restlessness that usually involves the lower extremities. This results in a compulsion to move. In most cases the movement is repetitive. The individual may cross, uncross, swing, or shift from one foot to the other. To the observer, this may appear as a persistent fidget. 23. 23. Question What medication would probably be ordered for the acutely aggressive schizophrenic client? • A. chlorpromazine (Thorazine) • B. haloperidol (Haldol) • C. lithium carbonate (Lithonate) • D. amitriptyline (Elavil) Incorrect Correct Answer: B. haloperidol (Haldol) Haloperidol administered I.M. or I.V. is the drug of choice for acute aggressive psychotic behavior. Haloperidol is a first-generation (typical) antipsychotic medication that is used widely around the world. Food and Drug Administration (FDA) approved the use of haloperidol is for schizophrenia, Tourette syndrome (control of tics and vocal utterances in adults and children), hyperactivity (which may present as impulsivity, difficulty maintaining attention, severe aggressivity, mood instability, and frustration intolerance), severe childhood behavioral problems (such as combative, explosive hyperexcitability), intractable hiccups. It is a typical antipsychotic because it works on positive symptoms of schizophrenia, such as hallucinations and delusions. • Option A: Chlorpromazine is also an antipsychotic drug; however, it causes more pronounced sedation than haloperidol. Chlorpromazine belongs to the category of typical antipsychotics or neuroleptics, also known as first-generation antipsychotics (FGAs). It produces its antipsychotic effect by the post-synaptic blockade at the D2 receptors in the mesolimbic pathway. However, the blockade of D2 receptors in the nigrostriatal pathway is responsible for its extrapyramidal side effects. • Option C: Lithium was the first mood stabilizer and is still the first-line treatment option, but is underutilized because it is an older drug. Lithium is a commonly prescribed drug for a manic episode in bipolar disorder as well as maintenance therapy of bipolar disorder in a patient with a history of a manic episode. The primary target symptoms of lithium are mania and unstable mood. • Option D: Amitriptyline is used for depression. Amitriptyline is in the tricyclic antidepressant (TCA) drug classification and acts by blocking the reuptake of both serotonin and norepinephrine neurotransmitters. The three-ring central structure, along with a side chain, is the basic structure of tricyclic antidepressants. Amitriptyline is a tertiary amine and has strong binding affinities for alpha-adrenergic, histamine (H1), and muscarinic (M1) receptors. It is more sedating and has increased anticholinergic properties compared to other TCAs. 24. 24. Question A client is admitted with a diagnosis of schizotypal personality disorder. Which signs would this client exhibit during social situations? • A. Aggressive behavior • B. Paranoid thoughts • C. Emotional affect • D. Independence needs Incorrect Correct Answer: B. Paranoid thoughts Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts. Isolation is a salient feature in the history of a schizoid patient. Rarely do they have close relationships, and often they will choose to participate in occupations that are solitary in nature. They infrequently experience strong emotion, express little to no desire for sexual activity with a partner, and tend to be ambivalent to criticism or praise. • Option A: Aggressive behavior is uncommon, although these clients may experience agitation with anxiety. Schizotypal can be differentiated with its more pronounced “magical” and eccentric thought processes. Paranoid, avoidant, and obsessive-compulsive personality disorders are also often on the clinician’s list of differential diagnoses. Unlike the aloofness observed in schizoid, however, patients with paranoid personality disorder are often overly resentful and can demonstrate explosive anger. • Option C: Their behavior is emotionally cold with a flattened affect, regardless of the situation. Individuals afflicted with personality disorders tend to externalize their problems, viewing others as the etiology of any conflict. If, by chance, a person with schizoid personality disorder presents in the clinical setting, DSM V has outlined specific diagnostic criteria for the clinician to use for evaluation. A pronounced blunted affect will immediately be observable on presentation. The patient will be disengaged, aloof, and will most likely diminish symptomatology. • Option D: These clients demonstrate a reduced capacity for close or dependent relationships. It is unlikely that a person with a schizoid personality disorder will present in the clinical setting of his own volition unless prompted by family, or as a result of a co-occurring disorder, such as depression. As with most personality disorders, the behavior is in synchrony with the ego, and thus the patient does not acknowledge the need to adapt his or her behavior. 25. 25. Question During the initial interview, a client with schizophrenia suddenly turns to the empty chair beside him and whispers, “Now just leave. I told you to stay home. There isn’t enough work here for both of us!” What is the nurse’s best initial response? • A. “When people are under stress, they may see things or hear things that others don’t. Is that what just happened?” • B. “I’m having a difficult time hearing you. Please look at me when you talk.” • C. “There is no one else in the room. What are you doing?” • D. “Who are you talking to? Are you hallucinating?” Incorrect Correct Answer: A. “When people are under stress, they may see things or hear things that others don’t. Is that what just happened?” This response makes the client feel that experiencing hallucinations is acceptable and promotes an open, therapeutic relationship. Authenticity, empathy, understanding of illness and the person, non-stigmatization, and the ability to work as a team are essential characteristics that the nurse must have for the therapeutic relationship to be effective. It is crucial to work with insights into the disease, the importance of adherence, and the reduction of self-stigma. Establishing a therapeutic relationship with the person with schizophrenia is therefore a constant challenge that must accompany the various stages of the disease in cooperation with the family and the community. • Option B: Directing the client to look at the nurse wouldn’t address the obvious issue of the hallucination. As for the presence of hallucinations, the NIC defines the nursing diagnosis of Hallucination Control(6510) as the promotion of safety, comfort, and the hallucinating patient’s orientation towards reality.2 Auditory hallucinations are the most frequent, so the nurse must observe certain signs, such as taking a listening posture, unmotivated laughter, talking to oneself, and blocks in thinking, lack of attention, and distraction. In the presence of these signs, the nurse should avoid touching the patient without warning, as the touch may be understood as a threat. • Option C: It is important that the patient understands that the voices are unreal and are part of the disease, and distraction techniques can be used to direct the patient towards reality. Listening to music or watching television may be a good technique to distract the patient from the attention given to auditory hallucinations. These interventions are intended to establish a relationship of empathy and trust with the patient, causing the patient to begin to be critical towards the disease so that new intervention strategies can be implemented. • Option D: Confrontational approaches are likely to elicit an uninformative or negative response. Nurses must display an attitude of acceptance to help the patient share the content of the hallucination. This sharing is important to avoid unwanted reactions towards the self or others, if command hallucinations are present. The hallucination should not be reinforced, and the word “voices” should be used to refer to it, avoiding the word “they” which may indicate validation. It is also essential to make the patient realize that the nurse does not share the perception by saying, “I know the voices for you are real, but I do not hear any voices.” 26. 26. Question The definition of nihilistic delusions is: • A. A false belief about the functioning of the body. • B. Belief that the body is deformed or defective in a specific way. • C. False ideas about the self, others, or the world • D. The inability to carry out motor activities. Incorrect Correct Answer: C. False ideas about the self, others, or the world. Nihilistic delusions are false ideas about the self, others, or the world. Nihilistic delusions, also known as délires de négation, are specific psychopathological entities characterized by the delusional belief of being dead, decomposed or annihilated, having lost one’s own internal organs or even not existing entirely as a human being. • Option A: Somatic delusions involve a false belief about the functioning of the body. Of the delusional symptoms, somatic delusions-those that pertain to the body-are rather rare. Somatic delusions are defined as fixed false beliefs that one’s bodily function or appearance is grossly abnormal. They are a poorly understood psychiatric symptom and pose a significant clinical challenge to clinicians. • Option B: Body dysmorphic disorder is characterized by a belief that the body is deformed or defective in a specific way. People who have body dysmorphic disorder (BDD) think about their real or perceived flaws for hours each day. They can’t control their negative thoughts and don’t believe people who tell them that they look fine. Their thoughts may cause severe emotional distress and interfere with their daily functioning. They may miss work or school, avoid social situation