MH- (SCHIZOPHRENIA SPECTRUM
AND OTHER PSYCHOTIC DISORDERS)
EXAM 2 QUESTIONS WITH COMPLETE
SOLUTIONS
Which client assessment finding would alert the nurse to question a diagnosis of
brief psychotic disorder?
a. Has impaired reality testing for a 24-hour period.
b. Has auditory hallucinations for the past 3 hours.
c. Has bizarre behavior for 1 day.
d. Has confusion for 3 weeks. - ANSWER-b. Has auditory hallucinations for the past
3 hours.
(This disorder is identified by the sudden onset of psychotic symptoms that may or
may not be preceded by a severe psychosocial stressor. These symptoms last at
least 1 day but less than 1 month and there is an eventual full return to the
premorbid level of functioning.)
Which data in the history would the nurse expect to find in a client diagnosed with
substance-induced psychotic disorder?
a. Had delirium
b. Had less severe withdrawal symptoms
c. Has an opioid use disorder
d. Has a fluid and electrolyte imbalance - ANSWER-c. Has an opioid use disorder
(The prominent hallucinations and delusions associated with substance-induced or
medication-induced disorder are found to be directly attributable to substance
intoxication or withdrawal, like opioid use disorder.)
Which modalities should a nurse recognize as integral parts of a treatment program
when planning care for clients diagnosed with schizophrenia spectrum disorder?
(Select all that apply.)
1. Group therapy
2. Medication management
3. Deterrent therapy
4. Supportive family therapy
5. Social skills training - ANSWER-1,2,4,5
The diagnosis of catatonic disorder due to another medical condition is made when
the client's medical history, physical examination, or laboratory findings provide
evidence that symptoms are directly attributed to which conditions? (Select all that
apply.)
1. Epilepsy
2. Hypothyroidism
3. Hyperadrenalism
4. Encephalitis
, 5. Hyperaphia - ANSWER-1,2,3,4
The nurse asks the client with schizophrenia spectrum disorder, "Do you receive
special messages from certain sources, such as the television or radio?" The nurse
is assessing which potential symptom of this disorder?
a. Loose associations
b. Paranoid delusions
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 he or she receives messages through the radio or TV is experiencing
delusions of reference. These delusions involve the client interpreting events within
the environment as being directed toward himself or herself. Clients with delusions of
reference believe that others are trying to send them messages in various ways, or
they must break a code to receive a message.)
A client diagnosed with schizophrenia spectrum disorder 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 response?
a. "Did you take your medicine this morning?"
b. "You are not going to hell. You are a good person."
c. "The voices must sound scary, but I do not hear any voices."
d. "The devil only talks to people who are receptive to his influence." - ANSWER-c.
"The voices must sound scary, but I do not hear any voices."
The client diagnosed with schizophrenia spectrum disorder tells a nurse about voices
commanding him to kill his ex-spouse. Which nursing diagnosis is priority for this
client?
a. Disturbed sensory perception
b. Altered thought processes
c. Risk for violence: directed toward others
d. Risk for injury - ANSWER-c. Risk for violence: directed toward others
Which nursing intervention would be most appropriate when caring for an agitated,
suspicious client diagnosed with schizophrenia spectrum disorder?
a. Supply neon lights and soft music.
b. Maintain continual eye contact throughout the interview.
c. Use therapeutic touch to increase trust and rapport.
d. Provide personal space to respect the client's boundaries. - ANSWER-d. Provide
personal space to respect the client's boundaries.
(The most appropriate nursing intervention is to provide personal space to respect
the client's boundaries. Providing personal space may serve to reduce anxiety and
thus reduce the client's risk for violence. The nurse should observe the client while
carrying out routine tasks.)
Which action would the nurse take to establish a trusting relationship with a client
diagnosed with schizophrenia spectrum disorder?
a. Establish personal contact with family members
AND OTHER PSYCHOTIC DISORDERS)
EXAM 2 QUESTIONS WITH COMPLETE
SOLUTIONS
Which client assessment finding would alert the nurse to question a diagnosis of
brief psychotic disorder?
a. Has impaired reality testing for a 24-hour period.
b. Has auditory hallucinations for the past 3 hours.
c. Has bizarre behavior for 1 day.
d. Has confusion for 3 weeks. - ANSWER-b. Has auditory hallucinations for the past
3 hours.
(This disorder is identified by the sudden onset of psychotic symptoms that may or
may not be preceded by a severe psychosocial stressor. These symptoms last at
least 1 day but less than 1 month and there is an eventual full return to the
premorbid level of functioning.)
Which data in the history would the nurse expect to find in a client diagnosed with
substance-induced psychotic disorder?
a. Had delirium
b. Had less severe withdrawal symptoms
c. Has an opioid use disorder
d. Has a fluid and electrolyte imbalance - ANSWER-c. Has an opioid use disorder
(The prominent hallucinations and delusions associated with substance-induced or
medication-induced disorder are found to be directly attributable to substance
intoxication or withdrawal, like opioid use disorder.)
Which modalities should a nurse recognize as integral parts of a treatment program
when planning care for clients diagnosed with schizophrenia spectrum disorder?
(Select all that apply.)
1. Group therapy
2. Medication management
3. Deterrent therapy
4. Supportive family therapy
5. Social skills training - ANSWER-1,2,4,5
The diagnosis of catatonic disorder due to another medical condition is made when
the client's medical history, physical examination, or laboratory findings provide
evidence that symptoms are directly attributed to which conditions? (Select all that
apply.)
1. Epilepsy
2. Hypothyroidism
3. Hyperadrenalism
4. Encephalitis
, 5. Hyperaphia - ANSWER-1,2,3,4
The nurse asks the client with schizophrenia spectrum disorder, "Do you receive
special messages from certain sources, such as the television or radio?" The nurse
is assessing which potential symptom of this disorder?
a. Loose associations
b. Paranoid delusions
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 he or she receives messages through the radio or TV is experiencing
delusions of reference. These delusions involve the client interpreting events within
the environment as being directed toward himself or herself. Clients with delusions of
reference believe that others are trying to send them messages in various ways, or
they must break a code to receive a message.)
A client diagnosed with schizophrenia spectrum disorder 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 response?
a. "Did you take your medicine this morning?"
b. "You are not going to hell. You are a good person."
c. "The voices must sound scary, but I do not hear any voices."
d. "The devil only talks to people who are receptive to his influence." - ANSWER-c.
"The voices must sound scary, but I do not hear any voices."
The client diagnosed with schizophrenia spectrum disorder tells a nurse about voices
commanding him to kill his ex-spouse. Which nursing diagnosis is priority for this
client?
a. Disturbed sensory perception
b. Altered thought processes
c. Risk for violence: directed toward others
d. Risk for injury - ANSWER-c. Risk for violence: directed toward others
Which nursing intervention would be most appropriate when caring for an agitated,
suspicious client diagnosed with schizophrenia spectrum disorder?
a. Supply neon lights and soft music.
b. Maintain continual eye contact throughout the interview.
c. Use therapeutic touch to increase trust and rapport.
d. Provide personal space to respect the client's boundaries. - ANSWER-d. Provide
personal space to respect the client's boundaries.
(The most appropriate nursing intervention is to provide personal space to respect
the client's boundaries. Providing personal space may serve to reduce anxiety and
thus reduce the client's risk for violence. The nurse should observe the client while
carrying out routine tasks.)
Which action would the nurse take to establish a trusting relationship with a client
diagnosed with schizophrenia spectrum disorder?
a. Establish personal contact with family members
