Chapter 15: Schizophrenia Spectrum and Other Psychotic Disorders
Halter: Varcarolis’s Canadian Psychiatric Mental Health Nursing, 2nd Edition
MULTIPLE CHOICE
1. A person has had difficulty keeping a job because of arguing with co-workers and accusing them
of conspiracy. Today the person shouts, “They’re all plotting to destroy me. Isn’t that true?”
Select the nurse’s most therapeutic response.
a. “Everyone here is trying to help you. No
one wants to harm you.”
b. “Feeling that people want to destroy you
must be very frightening.”
c. “That is not true. People here are trying to
help you if you will let them.”
d. “Staff members are health care providers
who are qualified to help you.”
ANS: B
Resist focusing on content; instead, focus on the feelings the patient is expressing. This strategy
prevents arguing about the reality of delusional beliefs. Such arguments increase patient anxiety
and the tenacity with which the patient holds to the delusion. The other options focus on content
and provide opportunity for argument.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
2. A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly scans the
environment. The patient states, “I saw two doctors talking in the hall. They were plotting to kill
me.” The nurse may correctly assess this behaviour as which of the following?
a. Echolalia
b. An idea of reference
c. A delusion of infidelity
d. An auditory hallucination
ANS: B
Ideas of reference are misinterpretations of the verbalizations or actions of others that give
special personal meanings to these behaviours; for example, when seeing two people talking, the
individual assumes they are talking about him or her. The other terms do not correspond with the
scenario.
DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
,3. A patient diagnosed with schizophrenia says, “My co-workers are out to get me. I also saw two
doctors plotting to kill me.” How does this patient perceive the environment?
a. Disorganized
b. Dangerous
c. Supportive
d. Bizarre
ANS: B
The patient sees the world as hostile and dangerous. This assessment is important because the
nurse can be more effective by using empathy to respond to the patient. Data are not present to
support any of the other options.
DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
4. When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol (Haldol)
was prescribed. The patient now says, “I stopped taking those pills. They made me feel like a
robot.” What are common side effects the nurse should validate with the patient?
a. Sedation and muscle stiffness
b. Sweating, nausea, and diarrhea
c. Mild fever, sore throat, and skin rash
d. Headache, watery eyes, and runny nose
ANS: A
Conventional antipsychotic drugs often produce sedation and extrapyramidal side effects such as
stiffness and gait disturbance, effects the patient might describe as making him or her “feel like a
robot.” The side effects mentioned in the other options are usually not associated with typical
antipsychotic therapy or would not have the effect described by the patient.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
5. Which of the following patient statements implies a hallucination that requires the nurse to
implement safety measures?
a. “I hear angels playing harps.”
b. “The voices say everyone is trying to kill
me.”
c. “My dead father tells me I am a good
person.”
d. “The voices talk only at night when I’m
trying to sleep.”
ANS: B
, The correct response indicates the patient is experiencing paranoia. Paranoia often leads to
fearfulness, and the patient may attempt to strike out at others to protect self. The distracters are
comforting hallucinations or do not indicate paranoia.
DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity
6. A patient’s care plan includes monitoring for auditory hallucinations. Which assessment findings
suggest the patient may be hallucinating?
a. Detachment and overconfidence
b. Darting eyes, tilted head, mumbling to self
c. Euphoric mood, hyperactivity,
distractibility
d. Foot tapping and repeatedly writing the
same phrase
ANS: B
Clues to hallucinations include eyes looking around the room as though to find the speaker,
tilting the head to one side as though listening intently, and grimacing, mumbling, or talking
aloud as though responding conversationally to someone.
DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
7. A health care provider considers which antipsychotic medication to prescribe for a patient
diagnosed with schizophrenia who has auditory hallucinations and poor social function. The
patient is also overweight and hypertensive. Which drug should the nurse advocate?
a. Clozapine (Clozaril)
b. Ziprasidone (Zeldox)
c. Olanzapine (Zyprexa)
d. Aripiprazole (Abilify)
ANS: D
Aripiprazole is a third-generation atypical antipsychotic effective against both positive and
negative symptoms of schizophrenia. It causes little or no weight gain and no increase in
glucose, high- or low-density lipoprotein cholesterol, or triglycerides, making it a reasonable
choice for a patient with obesity or heart disease. Clozapine may produce agranulocytosis,
making it a poor choice as a first-line agent. Ziprasidone may prolong the QT interval, making it
a poor choice for a patient with cardiac disease. Olanzapine fosters weight gain.
DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
8. A patient diagnosed with schizophrenia tells the nurse, “I eat skiller. Tend to end. Easter. It blows
away. Get it?” Select the nurse’s best response.
, a. “Nothing you are saying is clear.”
b. “Your thoughts are very disconnected.”
c. “Try to organize your thoughts and then
tell me again.”
d. “I am having difficulty understanding
what you are saying.”
ANS: D
When a patient’s speech is loosely associated, confused, and disorganized, pretending to
understand is useless. The nurse should tell the patient that he or she is having difficulty
understanding what the patient is saying. Clear messages and honesty are a vital part of working
effectively in psychiatric mental health nursing. An honest response lets the person know that the
nurse does not understand, would like to understand, and can be trusted to be honest. If a theme
is discernible, ask the patient to talk about the theme. The incorrect options tend to place blame
for the poor communication with the patient. The correct response places the difficulty with the
nurse rather than being accusatory.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
9. A patient diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates
waxy flexibility. Which patient needs are of priority importance?
a. Self-esteem
b. Psychosocial
c. Physiological
d. Self-actualization
ANS: C
Physiological needs must be met to preserve life. A patient with waxy flexibility must be fed by
hand or tube, toileted, given range-of-motion exercises, and so forth to preserve physiological
integrity. Higher level needs are of lesser concern.
DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
10. A patient diagnosed with schizophrenia demonstrates little spontaneous movement and has waxy
flexibility. The patient’s activities of daily living are severely compromised. An appropriate
outcome would be which of the following?
a. The patient demonstrates increased
interest in the environment by the end of
week 1.
b. The patient performs self-care activities
with coaching by the end of day 3.
Halter: Varcarolis’s Canadian Psychiatric Mental Health Nursing, 2nd Edition
MULTIPLE CHOICE
1. A person has had difficulty keeping a job because of arguing with co-workers and accusing them
of conspiracy. Today the person shouts, “They’re all plotting to destroy me. Isn’t that true?”
Select the nurse’s most therapeutic response.
a. “Everyone here is trying to help you. No
one wants to harm you.”
b. “Feeling that people want to destroy you
must be very frightening.”
c. “That is not true. People here are trying to
help you if you will let them.”
d. “Staff members are health care providers
who are qualified to help you.”
ANS: B
Resist focusing on content; instead, focus on the feelings the patient is expressing. This strategy
prevents arguing about the reality of delusional beliefs. Such arguments increase patient anxiety
and the tenacity with which the patient holds to the delusion. The other options focus on content
and provide opportunity for argument.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
2. A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly scans the
environment. The patient states, “I saw two doctors talking in the hall. They were plotting to kill
me.” The nurse may correctly assess this behaviour as which of the following?
a. Echolalia
b. An idea of reference
c. A delusion of infidelity
d. An auditory hallucination
ANS: B
Ideas of reference are misinterpretations of the verbalizations or actions of others that give
special personal meanings to these behaviours; for example, when seeing two people talking, the
individual assumes they are talking about him or her. The other terms do not correspond with the
scenario.
DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
,3. A patient diagnosed with schizophrenia says, “My co-workers are out to get me. I also saw two
doctors plotting to kill me.” How does this patient perceive the environment?
a. Disorganized
b. Dangerous
c. Supportive
d. Bizarre
ANS: B
The patient sees the world as hostile and dangerous. This assessment is important because the
nurse can be more effective by using empathy to respond to the patient. Data are not present to
support any of the other options.
DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
4. When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol (Haldol)
was prescribed. The patient now says, “I stopped taking those pills. They made me feel like a
robot.” What are common side effects the nurse should validate with the patient?
a. Sedation and muscle stiffness
b. Sweating, nausea, and diarrhea
c. Mild fever, sore throat, and skin rash
d. Headache, watery eyes, and runny nose
ANS: A
Conventional antipsychotic drugs often produce sedation and extrapyramidal side effects such as
stiffness and gait disturbance, effects the patient might describe as making him or her “feel like a
robot.” The side effects mentioned in the other options are usually not associated with typical
antipsychotic therapy or would not have the effect described by the patient.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
5. Which of the following patient statements implies a hallucination that requires the nurse to
implement safety measures?
a. “I hear angels playing harps.”
b. “The voices say everyone is trying to kill
me.”
c. “My dead father tells me I am a good
person.”
d. “The voices talk only at night when I’m
trying to sleep.”
ANS: B
, The correct response indicates the patient is experiencing paranoia. Paranoia often leads to
fearfulness, and the patient may attempt to strike out at others to protect self. The distracters are
comforting hallucinations or do not indicate paranoia.
DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity
6. A patient’s care plan includes monitoring for auditory hallucinations. Which assessment findings
suggest the patient may be hallucinating?
a. Detachment and overconfidence
b. Darting eyes, tilted head, mumbling to self
c. Euphoric mood, hyperactivity,
distractibility
d. Foot tapping and repeatedly writing the
same phrase
ANS: B
Clues to hallucinations include eyes looking around the room as though to find the speaker,
tilting the head to one side as though listening intently, and grimacing, mumbling, or talking
aloud as though responding conversationally to someone.
DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
7. A health care provider considers which antipsychotic medication to prescribe for a patient
diagnosed with schizophrenia who has auditory hallucinations and poor social function. The
patient is also overweight and hypertensive. Which drug should the nurse advocate?
a. Clozapine (Clozaril)
b. Ziprasidone (Zeldox)
c. Olanzapine (Zyprexa)
d. Aripiprazole (Abilify)
ANS: D
Aripiprazole is a third-generation atypical antipsychotic effective against both positive and
negative symptoms of schizophrenia. It causes little or no weight gain and no increase in
glucose, high- or low-density lipoprotein cholesterol, or triglycerides, making it a reasonable
choice for a patient with obesity or heart disease. Clozapine may produce agranulocytosis,
making it a poor choice as a first-line agent. Ziprasidone may prolong the QT interval, making it
a poor choice for a patient with cardiac disease. Olanzapine fosters weight gain.
DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
8. A patient diagnosed with schizophrenia tells the nurse, “I eat skiller. Tend to end. Easter. It blows
away. Get it?” Select the nurse’s best response.
, a. “Nothing you are saying is clear.”
b. “Your thoughts are very disconnected.”
c. “Try to organize your thoughts and then
tell me again.”
d. “I am having difficulty understanding
what you are saying.”
ANS: D
When a patient’s speech is loosely associated, confused, and disorganized, pretending to
understand is useless. The nurse should tell the patient that he or she is having difficulty
understanding what the patient is saying. Clear messages and honesty are a vital part of working
effectively in psychiatric mental health nursing. An honest response lets the person know that the
nurse does not understand, would like to understand, and can be trusted to be honest. If a theme
is discernible, ask the patient to talk about the theme. The incorrect options tend to place blame
for the poor communication with the patient. The correct response places the difficulty with the
nurse rather than being accusatory.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
9. A patient diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates
waxy flexibility. Which patient needs are of priority importance?
a. Self-esteem
b. Psychosocial
c. Physiological
d. Self-actualization
ANS: C
Physiological needs must be met to preserve life. A patient with waxy flexibility must be fed by
hand or tube, toileted, given range-of-motion exercises, and so forth to preserve physiological
integrity. Higher level needs are of lesser concern.
DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
10. A patient diagnosed with schizophrenia demonstrates little spontaneous movement and has waxy
flexibility. The patient’s activities of daily living are severely compromised. An appropriate
outcome would be which of the following?
a. The patient demonstrates increased
interest in the environment by the end of
week 1.
b. The patient performs self-care activities
with coaching by the end of day 3.
