SCHIZOPHRENIA AND OTHER
PSYCHOTIC DISORDERS NCLEX
EXAM QUESTIONS #4 CORRECT
ANSWERS
Which statement should indicate to a nurse that an individual is experiencing a
delusion?
A. "There's an alien growing in my liver."
B. "I see my dead husband everywhere I go."
C. "The IRS may audit my taxes."
D. "I'm not going to eat my food. It smells like brimstone." - ANSWER-ANS: A
The nurse should recognize that a client who claims that an alien is inside his or her
body is experiencing a delusion. Delusions are false personal beliefs that are
inconsistent with the person's intelligence or cultural background.
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 - ANSWER-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 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 - ANSWER-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 nurse is caring for a client who is experiencing a flat affect, paranoid delusions,
anhedonia, anergia, neologisms, and echolalia. Which statement correctly
differentiates the client's positive and negative symptoms of schizophrenia?
A. Paranoid delusions, anhedonia, and anergia are positive symptoms of
schizophrenia.
B. Paranoid delusions, neologisms, and echolalia are positive symptoms of
schizophrenia.
C. Paranoid delusions, anergia, and echolalia are negative symptoms of
schizophrenia.
D. Paranoid delusions, flat affect, and anhedonia are negative symptoms of
schizophrenia. - ANSWER-ANS: B
The nurse should recognize that positive symptoms of schizophrenia include
paranoid delusions, neologisms, and echolalia. The negative symptoms of
schizophrenia include flat affect, anhedonia, and anergia. Positive symptoms reflect
an excess or distortion of normal functions. Negative symptoms reflect a decrease or
loss of normal functions.
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 - ANSWER-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.
Which nursing intervention would be most appropriate when caring for an acutely
agitated client diagnosed with paranoid schizophrenia?
A. Provide 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-ANS: D
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.
Which nursing behavior will enhance the establishment of a trusting relationship with
a client diagnosed with schizophrenia?
A. Establishing personal contact with family members.
B. Being reliable, honest, and consistent during interactions.
C. Sharing limited personal information.
PSYCHOTIC DISORDERS NCLEX
EXAM QUESTIONS #4 CORRECT
ANSWERS
Which statement should indicate to a nurse that an individual is experiencing a
delusion?
A. "There's an alien growing in my liver."
B. "I see my dead husband everywhere I go."
C. "The IRS may audit my taxes."
D. "I'm not going to eat my food. It smells like brimstone." - ANSWER-ANS: A
The nurse should recognize that a client who claims that an alien is inside his or her
body is experiencing a delusion. Delusions are false personal beliefs that are
inconsistent with the person's intelligence or cultural background.
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 - ANSWER-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 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 - ANSWER-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 nurse is caring for a client who is experiencing a flat affect, paranoid delusions,
anhedonia, anergia, neologisms, and echolalia. Which statement correctly
differentiates the client's positive and negative symptoms of schizophrenia?
A. Paranoid delusions, anhedonia, and anergia are positive symptoms of
schizophrenia.
B. Paranoid delusions, neologisms, and echolalia are positive symptoms of
schizophrenia.
C. Paranoid delusions, anergia, and echolalia are negative symptoms of
schizophrenia.
D. Paranoid delusions, flat affect, and anhedonia are negative symptoms of
schizophrenia. - ANSWER-ANS: B
The nurse should recognize that positive symptoms of schizophrenia include
paranoid delusions, neologisms, and echolalia. The negative symptoms of
schizophrenia include flat affect, anhedonia, and anergia. Positive symptoms reflect
an excess or distortion of normal functions. Negative symptoms reflect a decrease or
loss of normal functions.
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 - ANSWER-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.
Which nursing intervention would be most appropriate when caring for an acutely
agitated client diagnosed with paranoid schizophrenia?
A. Provide 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-ANS: D
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.
Which nursing behavior will enhance the establishment of a trusting relationship with
a client diagnosed with schizophrenia?
A. Establishing personal contact with family members.
B. Being reliable, honest, and consistent during interactions.
C. Sharing limited personal information.
