A 16-year-old-client diagnosed with paranoid schizophrenia experiences command
hallucinations to harm others. The client's parents ask a nurse, "Where do the voices
come from?" Which is the appropriate nursing reply?
A. "Your child has a chemical imbalance of the brain which leads to altered thoughts."
B. "Your child's hallucinations are caused by medication interactions."
C. "Your child has too little serotonin in the brain causing delusions and hallucinations."
D. "Your child's abnormal hormonal changes have precipitated auditory hallucinations."
- ANS: A
The nurse should explain that a chemical imbalance of the brain leads to altered
thought processes. Hallucinations, or false sensory perceptions, may occur in all five
senses. The client who hears voices is experiencing an auditory hallucination.
A client diagnosed with chronic schizophrenia presents in an emergency department
(ED) with uncontrollable tongue movements, stiff neck, and difficulty swallowing. The
nurse would expect the physician to recognize which condition and implement which
treatment?
A. Neuroleptic malignant syndrome and treat by discontinuing antipsychotic medications
B. Agranulocytosis and treat by administration of clozapine (Clozaril)
C. Extrapyramidal symptoms and treat by administration of benztropine (Cogentin)
D. Tardive dyskinesia and treat by discontinuing antipsychotic medications - ANS: D
The nurse should expect that an ED physician would diagnose the client with tardive
dyskinesia and discontinue antipsychotic medications. Tardive dyskinesia is a condition
of abnormal involuntary movements of the mouth, tongue, trunk, and extremities that
can be an irreversible side effect of typical antipsychotic medications.
A client diagnosed with paranoid schizophrenia states, "My psychiatrist is out to get me.
I'm sad that the voice is telling me to stop him." What symptom is the client exhibiting,
and what is the nurse's legal responsibility related to this symptom?
A. Magical thinking; administer an antipsychotic medication
B. Persecutory delusions; orient the client to reality
C. Command hallucinations; warn the psychiatrist
D. Altered thought processes; call an emergency treatment team meeting - ANS: C
The nurse should determine that the client is exhibiting command hallucinations. The
nurse's legal responsibility is to warn the psychiatrist of the potential for harm. A client
who is demonstrating a risk for violence could potentially become physically,
emotionally, and/or sexually harmful to others or to self.
A client diagnosed with psychosis NOS (not otherwise specified) tells a nurse about
voices telling him to kill the president. Which nursing diagnosis should the nurse
prioritize for this client?
A. Disturbed sensory perception
,B. Altered thought processes
C. Risk for violence: directed toward others
D. Risk for injury - ANS: C
The nurse should prioritize the diagnosis risk for violence: directed toward others. A
client who hears voices telling him to kill someone is at risk for responding and reacting
to the command hallucination. Other risk factors for violence include aggressive body
language, verbal aggression, catatonic excitement, and rage reactions.
A client diagnosed with schizoaffective disorder is admitted for social skills training.
Which information should be taught by the nurse?
A. The side effects of medications
B. Deep breathing techniques to decrease stress
C. How to make eye contact when communicating
D. How to be a leader - ANS: C
The nurse should plan to teach the client how to make eye contact when
communicating. Social skills, such as making eye contact, can assist clients in
communicating needs and maintaining connectedness.
A client diagnosed with schizophrenia is prescribed clozapine (Clozaril). Which client
symptoms related to the side effects of this medication should prompt a nurse to
intervene immediately?
A. Sore throat, fever, and malaise
B. Akathisia and hypersalivation
C. Akinesia and insomnia
D. Dry mouth and urinary retention - ANS: A
The nurse should intervene immediately if the client experiences a sore throat, fever,
and malaise when taking the atypical antipsychotic drug clozapine (Clozaril). Clozapine
can have a serious side effect of agranulocytosis, in which a potentially fatal drop in
white blood cells can occur. Symptoms of infectious processes would alert the nurse to
this potential.
A client diagnosed with schizophrenia is slow to respond and appears to be listening to
unseen others. Which medication should a nurse expect a physician to order to address
this type of symptom?
A. Haloperidol (Haldol) to address the negative symptom
B. Clonazepam (Klonopin) to address the positive symptom
C. Risperidone (Risperdal) to address the positive symptom
D. Clozapine (Clozaril) to address the negative symptom - ANS: C
The nurse should expect the physician to order risperidone (Risperdal) to address the
positive symptoms of schizophrenia. Risperidone (Risperdal) is an atypical antipsychotic
used to reduce positive symptoms, including disturbances in content of thought
(delusions), form of thought (neologisms), or sensory perception (hallucinations).
,A client diagnosed with schizophrenia states, "Can't you hear him? It's the devil. He's
telling me I'm going to hell." Which is the most appropriate nursing reply?
A. "Did you take your medicine this morning?"
B. "You are not going to hell. You are a good person."
C. "I'm sure the voices sound scary. The devil is not talking to you. This is part of your
illness."
D. "The devil only talks to people who are receptive to his influence." - ANS: C
The most appropriate reply by the nurse is to reassure the client with an accepting
attitude while not reinforcing the hallucination. Reminding the client that "the voices" are
a part of his or her illness is a way to help the client accept that the hallucinations are
not real.
A client diagnosed with schizophrenia takes an antipsychotic agent daily. Which
assessment finding should a nurse immediately report to the client's attending
psychiatrist?
A. Respirations of 22/minute
B. Weight gain of 8 pounds in 2 months
C. Temperature of 104F (40C)
D. Excessive salivation - ANS: C
When assessing a client diagnosed with schizophrenia who takes an antipsychotic
agent daily, the nurse should immediately address a temperature of 104F (40C). A
temperature this high can be a symptom of the rare but life-threatening neuroleptic
malignant syndrome.
A client diagnosed with schizophrenia tells a nurse, "The 'Shopatouliens' took my shoes
out of my room last night." Which is an appropriate charting entry to describe this
client's statement?
A. "The client is experiencing command hallucinations."
B. "The client is expressing a neologism."
C. "The client is experiencing a paranoid delusion."
D. "The client is verbalizing a word salad." - ANS: B
The nurse should describe the client's statement as experiencing a neologism. A
neologism is when a client invents a new word that is meaningless to others but may
have symbolic meaning to the client. Word salad refers to a group of words that are put
together randomly.
A client has been recently admitted to an inpatient psychiatric unit. Which intervention
should the nurse plan to use to reduce the client's focus on delusional thinking?
A. Present evidence that supports the reality of the situation
B. Focus on feelings suggested by the delusion
C. Address the delusion with logical explanations
D. Explore reasons why the client has the delusion - ANS: B
, The nurse should focus on the client's feelings rather than attempt to change the client's
delusional thinking by the use of evidence or logical explanations. Delusional thinking is
usually fixed, and clients will continue to have the belief in spite of obvious proof that the
belief is false or irrational.
A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol) 50 mg
bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg HS. Which client
behavior would warrant the nurse to administer benztropine?
A. Tactile hallucinations
B. Tardive dyskinesia
C. Restlessness and muscle rigidity
D. Reports of hearing disturbing voices - ANS: C
The symptom of tactile hallucinations and reports of hearing disturbing voices would be
addressed by an antipsychotic medication such as haloperidol. Tardive dyskinesia, a
potentially irreversible condition, would warrant the discontinuation of an antipsychotic
medication such as haloperidol. An anticholinergic medication such as benztropine
would be used to treat the extrapyramidal symptoms of restlessness and muscle rigidity.
A client states, "I hear voices that tell me that I am evil." Which outcome related to these
symptoms should the nurse expect this client to accomplish by discharge?
A. The client will verbalize the reason the voices make derogatory statements.
B. The client will not hear auditory hallucinations.
C. The client will identify events that increase anxiety and illicit hallucinations.
D. The client will positively integrate the voices into the client's personality structure. -
ANS: C
It is unrealistic to expect the client to completely stop hearing voices. Even when
compliant with antipsychotic medications, clients may still hear voices. It would be
realistic to expect the client to associate stressful events with an increase in auditory
hallucinations. By this recognition the client can anticipate symptoms and initiate
appropriate coping skills.
A college student has quit attending classes, isolates self due to hearing voices, and
yells accusations at fellow students. Based on this information, which nursing diagnosis
should the nurse prioritize?
A. Altered thought processes R/T hearing voices AEB increased anxiety
B. Risk for other-directed violence R/T yelling accusations
C. Social isolation R/T paranoia AEB absence from classes
D. Risk for self-directed violence R/T depressed mood - ANS: B
The nursing diagnosis that must be prioritized in this situation should be risk for other-
directed violence R/T yelling accusations. Hearing voices and yelling accusations
indicates a potential for violence, and this potential safety issue should be prioritized.
hallucinations to harm others. The client's parents ask a nurse, "Where do the voices
come from?" Which is the appropriate nursing reply?
A. "Your child has a chemical imbalance of the brain which leads to altered thoughts."
B. "Your child's hallucinations are caused by medication interactions."
C. "Your child has too little serotonin in the brain causing delusions and hallucinations."
D. "Your child's abnormal hormonal changes have precipitated auditory hallucinations."
- ANS: A
The nurse should explain that a chemical imbalance of the brain leads to altered
thought processes. Hallucinations, or false sensory perceptions, may occur in all five
senses. The client who hears voices is experiencing an auditory hallucination.
A client diagnosed with chronic schizophrenia presents in an emergency department
(ED) with uncontrollable tongue movements, stiff neck, and difficulty swallowing. The
nurse would expect the physician to recognize which condition and implement which
treatment?
A. Neuroleptic malignant syndrome and treat by discontinuing antipsychotic medications
B. Agranulocytosis and treat by administration of clozapine (Clozaril)
C. Extrapyramidal symptoms and treat by administration of benztropine (Cogentin)
D. Tardive dyskinesia and treat by discontinuing antipsychotic medications - ANS: D
The nurse should expect that an ED physician would diagnose the client with tardive
dyskinesia and discontinue antipsychotic medications. Tardive dyskinesia is a condition
of abnormal involuntary movements of the mouth, tongue, trunk, and extremities that
can be an irreversible side effect of typical antipsychotic medications.
A client diagnosed with paranoid schizophrenia states, "My psychiatrist is out to get me.
I'm sad that the voice is telling me to stop him." What symptom is the client exhibiting,
and what is the nurse's legal responsibility related to this symptom?
A. Magical thinking; administer an antipsychotic medication
B. Persecutory delusions; orient the client to reality
C. Command hallucinations; warn the psychiatrist
D. Altered thought processes; call an emergency treatment team meeting - ANS: C
The nurse should determine that the client is exhibiting command hallucinations. The
nurse's legal responsibility is to warn the psychiatrist of the potential for harm. A client
who is demonstrating a risk for violence could potentially become physically,
emotionally, and/or sexually harmful to others or to self.
A client diagnosed with psychosis NOS (not otherwise specified) tells a nurse about
voices telling him to kill the president. Which nursing diagnosis should the nurse
prioritize for this client?
A. Disturbed sensory perception
,B. Altered thought processes
C. Risk for violence: directed toward others
D. Risk for injury - ANS: C
The nurse should prioritize the diagnosis risk for violence: directed toward others. A
client who hears voices telling him to kill someone is at risk for responding and reacting
to the command hallucination. Other risk factors for violence include aggressive body
language, verbal aggression, catatonic excitement, and rage reactions.
A client diagnosed with schizoaffective disorder is admitted for social skills training.
Which information should be taught by the nurse?
A. The side effects of medications
B. Deep breathing techniques to decrease stress
C. How to make eye contact when communicating
D. How to be a leader - ANS: C
The nurse should plan to teach the client how to make eye contact when
communicating. Social skills, such as making eye contact, can assist clients in
communicating needs and maintaining connectedness.
A client diagnosed with schizophrenia is prescribed clozapine (Clozaril). Which client
symptoms related to the side effects of this medication should prompt a nurse to
intervene immediately?
A. Sore throat, fever, and malaise
B. Akathisia and hypersalivation
C. Akinesia and insomnia
D. Dry mouth and urinary retention - ANS: A
The nurse should intervene immediately if the client experiences a sore throat, fever,
and malaise when taking the atypical antipsychotic drug clozapine (Clozaril). Clozapine
can have a serious side effect of agranulocytosis, in which a potentially fatal drop in
white blood cells can occur. Symptoms of infectious processes would alert the nurse to
this potential.
A client diagnosed with schizophrenia is slow to respond and appears to be listening to
unseen others. Which medication should a nurse expect a physician to order to address
this type of symptom?
A. Haloperidol (Haldol) to address the negative symptom
B. Clonazepam (Klonopin) to address the positive symptom
C. Risperidone (Risperdal) to address the positive symptom
D. Clozapine (Clozaril) to address the negative symptom - ANS: C
The nurse should expect the physician to order risperidone (Risperdal) to address the
positive symptoms of schizophrenia. Risperidone (Risperdal) is an atypical antipsychotic
used to reduce positive symptoms, including disturbances in content of thought
(delusions), form of thought (neologisms), or sensory perception (hallucinations).
,A client diagnosed with schizophrenia states, "Can't you hear him? It's the devil. He's
telling me I'm going to hell." Which is the most appropriate nursing reply?
A. "Did you take your medicine this morning?"
B. "You are not going to hell. You are a good person."
C. "I'm sure the voices sound scary. The devil is not talking to you. This is part of your
illness."
D. "The devil only talks to people who are receptive to his influence." - ANS: C
The most appropriate reply by the nurse is to reassure the client with an accepting
attitude while not reinforcing the hallucination. Reminding the client that "the voices" are
a part of his or her illness is a way to help the client accept that the hallucinations are
not real.
A client diagnosed with schizophrenia takes an antipsychotic agent daily. Which
assessment finding should a nurse immediately report to the client's attending
psychiatrist?
A. Respirations of 22/minute
B. Weight gain of 8 pounds in 2 months
C. Temperature of 104F (40C)
D. Excessive salivation - ANS: C
When assessing a client diagnosed with schizophrenia who takes an antipsychotic
agent daily, the nurse should immediately address a temperature of 104F (40C). A
temperature this high can be a symptom of the rare but life-threatening neuroleptic
malignant syndrome.
A client diagnosed with schizophrenia tells a nurse, "The 'Shopatouliens' took my shoes
out of my room last night." Which is an appropriate charting entry to describe this
client's statement?
A. "The client is experiencing command hallucinations."
B. "The client is expressing a neologism."
C. "The client is experiencing a paranoid delusion."
D. "The client is verbalizing a word salad." - ANS: B
The nurse should describe the client's statement as experiencing a neologism. A
neologism is when a client invents a new word that is meaningless to others but may
have symbolic meaning to the client. Word salad refers to a group of words that are put
together randomly.
A client has been recently admitted to an inpatient psychiatric unit. Which intervention
should the nurse plan to use to reduce the client's focus on delusional thinking?
A. Present evidence that supports the reality of the situation
B. Focus on feelings suggested by the delusion
C. Address the delusion with logical explanations
D. Explore reasons why the client has the delusion - ANS: B
, The nurse should focus on the client's feelings rather than attempt to change the client's
delusional thinking by the use of evidence or logical explanations. Delusional thinking is
usually fixed, and clients will continue to have the belief in spite of obvious proof that the
belief is false or irrational.
A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol) 50 mg
bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg HS. Which client
behavior would warrant the nurse to administer benztropine?
A. Tactile hallucinations
B. Tardive dyskinesia
C. Restlessness and muscle rigidity
D. Reports of hearing disturbing voices - ANS: C
The symptom of tactile hallucinations and reports of hearing disturbing voices would be
addressed by an antipsychotic medication such as haloperidol. Tardive dyskinesia, a
potentially irreversible condition, would warrant the discontinuation of an antipsychotic
medication such as haloperidol. An anticholinergic medication such as benztropine
would be used to treat the extrapyramidal symptoms of restlessness and muscle rigidity.
A client states, "I hear voices that tell me that I am evil." Which outcome related to these
symptoms should the nurse expect this client to accomplish by discharge?
A. The client will verbalize the reason the voices make derogatory statements.
B. The client will not hear auditory hallucinations.
C. The client will identify events that increase anxiety and illicit hallucinations.
D. The client will positively integrate the voices into the client's personality structure. -
ANS: C
It is unrealistic to expect the client to completely stop hearing voices. Even when
compliant with antipsychotic medications, clients may still hear voices. It would be
realistic to expect the client to associate stressful events with an increase in auditory
hallucinations. By this recognition the client can anticipate symptoms and initiate
appropriate coping skills.
A college student has quit attending classes, isolates self due to hearing voices, and
yells accusations at fellow students. Based on this information, which nursing diagnosis
should the nurse prioritize?
A. Altered thought processes R/T hearing voices AEB increased anxiety
B. Risk for other-directed violence R/T yelling accusations
C. Social isolation R/T paranoia AEB absence from classes
D. Risk for self-directed violence R/T depressed mood - ANS: B
The nursing diagnosis that must be prioritized in this situation should be risk for other-
directed violence R/T yelling accusations. Hearing voices and yelling accusations
indicates a potential for violence, and this potential safety issue should be prioritized.
