Correct Answers
Positive versus Negative Symptoms
The nurse is caring for a client with signs and symptoms of psychosis. Drag and drop
the symptoms to the columns to indicate whether they are positive or negative. Correct
Answer Positive Symptoms:
Word Salad
Somatic Delusions
Hyperactivity
Negative Symptoms:
Alogia
Asociality
Blunting of affect
Hallucinations
The nurse in the inpatient psychiatric unit is observing clients in the television room.
One of the clients appears to be hallucinating. They are swearing loudly at the television
and are becoming increasingly agitated. For each intervention, click to specify if each
nursing intervention is indicated or not indicated. Correct Answer Not Indicated-
Authoritative voice
Indicated
Not Indicated- Instruct other team members to disregard client's behavior
Indicated
Indicated
Perceptual Disturbances
The acute mental health unit nurse is caring for a client in the group room with four
other clients. The client is visibly agitated. The client is pacing, covering their ears with
their hands, and shouting, "No! I know you just want my brain."
The nurse prepares to take immediate action and suspects the client is having:
________________ hallucinations, as evidenced by the client_________________.
Correct Answer Auditory
Covering their ears
Nursing Actions
The nurse is caring for a client admitted to the psychiatric unit after being found by the
police, dripping blood from their left arm, walking naked down the middle of the street at
, 1400. The client constantly shouts, "I am the real Elvis!" Which nursing intervention
should the nurse implement when working with this client? Correct Answer Consistently
use the client's name.
Clinical Manifestations of Psychosis
The school nurse is caring for a 16-year-old who experienced subtle lacerations in their
left hand after punching a classroom wall while shouting, "Give me my homework," to
the wall continuously. The client's parent was called, and the parent shared with the
nurse that the client had been behaving "differently" in the past three months. The
parent provided several examples of this behavior. Drag the statements by the parent
that indicate a behavior considered to be a clinical manifestation of psychosis to the
boxes on the right. Select all that apply. Correct Answer "My child has been having
conversations in his room, but no one is there."
"My child has suddenly stopped bathing and brushing their teeth."
"My child is constantly preoccupied that the neighbors are watching them."
Safety
The emergency room nurse is caring for a client who a family member brought after
they started reporting hearing voices saying, "Do bad things." Which nursing
intervention is the most important for this client? Correct Answer Assess the nature of
the commands by asking the client what the voices are saying.
Safe Environment
The nurse in the psychiatric unit is admitting a client who experienced command
hallucinations and injured their partner with a vase because "the voice told them to do
so." For each nursing action, click to specify if it contributes or does not contribute to a
safe environment in the nursing unit. Correct Answer Does not contribute- Increasing
stimulation in the environment
Contributes
Contributes
Contributes
Assessment: Findings to Report
The nurse is assessing a client being treated for refractory schizophrenia who was
newly prescribed clozapine one week ago. Drag the assessment findings that the nurse
should report to the healthcare provider to the boxes on the right. Correct Answer Client
reports malasie
Client reports fever
Client reports sore throat
Medication to Treat Schizophrenia