Test Bank For Keltners Psychiatric Nursing, 9th Edition By
Debbie Steele Chapter , All Chapters with Answers and
Rationals
1. A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which
nursing action should be prioritized to maintain this clients safety?
A. Assess for medication noncompliance
B. Note escalating behaviors and intervene immediately
C. Interpret attempts at communication
D. Assess triggers for bizarre, inappropriate behaviors - ANSWER: ANS: Note escalating behaviors and
intervene immediately
The nurse should note escalating behaviors and intervene immediately to maintain this clients safety.
2. 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 - ANSWER: C. How to make eye contact when communicating
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
3. A 16-year-old client diagnosed with schizophrenia experiences command hallucinations to harm
others. The clients 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 childs hallucinations are caused by medication interactions.
C. Your child has too little serotonin in the brain, causing delusions and hallucinations.
D. Your childs abnormal hormonal changes have precipitated auditory hallucinations. - ANSWER: A.
Your child has a chemical imbalance of the brain, which leads to altered thoughts.
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.
4. Parents ask a nurse how they should reply when their child, diagnosed with schizophrenia, tells
them that voices command him to harm others. Which is the appropriate nursing reply?
A. Tell him to stop discussing the voices.
, B. Ignore what he is saying, while attempting to discover the underlying cause.
C. Focus on the feelings generated by the hallucinations and present reality.
D. Present objective evidence that the voices are not real. - ANSWER: C. Focus on the feelings
generated by the hallucinations and present reality.
The most appropriate response by the nurse is to instruct the parents to focus on the feelings
generated by the hallucinations and present reality. The parents should maintain an attitude of
acceptance to encourage communication but should not reinforce the hallucinations by exploring
details of content. It is inappropriate to present logical arguments to persuade the client to accept the
hallucinations as not real.
5. A nurse is assessing a client diagnosed with schizophrenia. The nurse asks the client, Do you receive
special messages from certain sources, such as the television or radio? Which potential symptom of
this disorder is the nurse assessing?
A. Thought insertion
B. Paranoia
C. Magical thinking
D. Delusions of reference - ANSWER: D. Delusions of reference
The nurse is assessing for the potential symptom of delusions of reference. A client who believes that
he or she receives messages through the radio is experiencing delusions of reference. When a client
experiences these delusions, he or she interprets all events within the environment as personal
references.
6. 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 clients statement?
A. The client is experiencing command hallucinations.
B. The client is expressing a neologism.
C. The client is experiencing a paranoia.
D. The client is verbalizing a word salad. - ANSWER: B. The client is expressing a neologism.
The nurse should describe the clients 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.
7. During an admission assessment, a nurse asks a client diagnosed with schizophrenia, Have you ever
felt that certain objects or persons have control over your behavior? The nurse is assessing for which
type of thought disruption?
A. Delusions of persecution
B. Delusions of influence
C. Delusions of reference
D. Delusions of grandeur - ANSWER: B. Delusions of influence
Debbie Steele Chapter , All Chapters with Answers and
Rationals
1. A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which
nursing action should be prioritized to maintain this clients safety?
A. Assess for medication noncompliance
B. Note escalating behaviors and intervene immediately
C. Interpret attempts at communication
D. Assess triggers for bizarre, inappropriate behaviors - ANSWER: ANS: Note escalating behaviors and
intervene immediately
The nurse should note escalating behaviors and intervene immediately to maintain this clients safety.
2. 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 - ANSWER: C. How to make eye contact when communicating
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
3. A 16-year-old client diagnosed with schizophrenia experiences command hallucinations to harm
others. The clients 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 childs hallucinations are caused by medication interactions.
C. Your child has too little serotonin in the brain, causing delusions and hallucinations.
D. Your childs abnormal hormonal changes have precipitated auditory hallucinations. - ANSWER: A.
Your child has a chemical imbalance of the brain, which leads to altered thoughts.
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.
4. Parents ask a nurse how they should reply when their child, diagnosed with schizophrenia, tells
them that voices command him to harm others. Which is the appropriate nursing reply?
A. Tell him to stop discussing the voices.
, B. Ignore what he is saying, while attempting to discover the underlying cause.
C. Focus on the feelings generated by the hallucinations and present reality.
D. Present objective evidence that the voices are not real. - ANSWER: C. Focus on the feelings
generated by the hallucinations and present reality.
The most appropriate response by the nurse is to instruct the parents to focus on the feelings
generated by the hallucinations and present reality. The parents should maintain an attitude of
acceptance to encourage communication but should not reinforce the hallucinations by exploring
details of content. It is inappropriate to present logical arguments to persuade the client to accept the
hallucinations as not real.
5. A nurse is assessing a client diagnosed with schizophrenia. The nurse asks the client, Do you receive
special messages from certain sources, such as the television or radio? Which potential symptom of
this disorder is the nurse assessing?
A. Thought insertion
B. Paranoia
C. Magical thinking
D. Delusions of reference - ANSWER: D. Delusions of reference
The nurse is assessing for the potential symptom of delusions of reference. A client who believes that
he or she receives messages through the radio is experiencing delusions of reference. When a client
experiences these delusions, he or she interprets all events within the environment as personal
references.
6. 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 clients statement?
A. The client is experiencing command hallucinations.
B. The client is expressing a neologism.
C. The client is experiencing a paranoia.
D. The client is verbalizing a word salad. - ANSWER: B. The client is expressing a neologism.
The nurse should describe the clients 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.
7. During an admission assessment, a nurse asks a client diagnosed with schizophrenia, Have you ever
felt that certain objects or persons have control over your behavior? The nurse is assessing for which
type of thought disruption?
A. Delusions of persecution
B. Delusions of influence
C. Delusions of reference
D. Delusions of grandeur - ANSWER: B. Delusions of influence
