C HAPTER 12: S CHIZOPHRENIA S PECTRUM
D ISORDERS
Varcarolis’ Foundations of Psychiatric -Mental Health Nursing: 8th Edition
MULTIPLE CHOICE
1. A patient took trifluoperazine 30 mg po dail y for 3 years. The clinic nurse
notes that the patient grimaces and constantl y smacks both lips . The
patients neck and shoulders twist in a slow, snakelike motion. Which
problem would the nurse suspect?
a. Agranulocytosis
b. Tardive dyskinesia
c. Tourettes syndrome
d. Anticholinergic effects
ANS: B
Tardive dyskinesia is a neuroleptic -induced condition invo lving the
face, trunk, and limbs. Involuntary movements, such as tongue
thrusting; licking; blowing; irregular movements of the arms, neck, and
shoulders; rocking; hip jerks; and pelvic thrusts, are seen. These
s ymptoms are frequentl y not reversible even w hen the drug is
discontinued. The scenario does not present evidence consistent with
the other disorders mentioned. Agranulocytosis is a blood disorder.
Tourettes syndrome is a condition in which tics are present.
Anticholinergic effects include dry mouth, blurred vision, flushing,
constipation, and dry eyes.
, PTS: 1 DIF: Cognitive Level: Anal yze (Anal ysis) REF: 206
TOP: Nursing Process: Evaluation MSC: Client Needs:
Physiological Integrity
2. A nurse sits with a patient diagnosed with schizophrenia. The pati ent
starts to laugh uncontrollabl y, although the nurse has not said anything
funny. Select the nurses best response.
a. Why are you laughing?
b. Please share the joke with me.
c. I dont think I said anything funny.
d. Youre laughing. Tell me whats happening.
ANS: D
The patient is likel y laughing in response to inner stimuli, such as
hallucinations or fantasy. Focus on the hallucinatory clue (the patients
laughter) and then elicit the patients observation. The incorrect options
are less useful in eliciting a response: no joke may be involved, why
questions are difficult to answer, and the patient is probabl y not
focusing on what the nurse said in the first place.
PTS: 1 DIF: Cognitive Level: Appl y (Application)
REF: 197 TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
3. The nurse assesses a patient diagnosed with schizophrenia. Which
assessment finding would the nurse regard as a negative symptom of
schizophrenia?
a. Auditory hallucinations
b. Delusions of grandeur
, c. Poor personal hygiene
d. Psychomotor agitation
ANS: C
Negative symptoms include apathy, anhedonia, poor social functioning,
and povert y of thought. Poor personal hygiene is an example of poor
social functioning. The distracters are positive symptoms of
schizophrenia. See relationship to audience response question.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
REF: 198 TOP: Nursing Process: Assessment MSC:
Client Needs: Psychosocial Integrit y
4. What assessment findings mark the prodromal stage of schizophrenia?
a. Withdrawal, misinterpreting, poor concentration, and preoccupation
with religion
b. Auditory hallucinations, ideas of reference, thought insertion, and
broadcasting
c. Stereot yped behavior, echopraxia, echolalia, and waxy flexibilit y
d. Loose associations, concr ete thinking, and echolalia neologisms
ANS: A
Withdrawal, misinterpreting, poor concentration, and preoccupation
with religion are prodromal symptoms, the symptoms that are present
before the development of florid symptoms. The incorrect options each
list the positive sym ptoms of schizophrenia that might be apparent
during the acute stage of the illness.
D ISORDERS
Varcarolis’ Foundations of Psychiatric -Mental Health Nursing: 8th Edition
MULTIPLE CHOICE
1. A patient took trifluoperazine 30 mg po dail y for 3 years. The clinic nurse
notes that the patient grimaces and constantl y smacks both lips . The
patients neck and shoulders twist in a slow, snakelike motion. Which
problem would the nurse suspect?
a. Agranulocytosis
b. Tardive dyskinesia
c. Tourettes syndrome
d. Anticholinergic effects
ANS: B
Tardive dyskinesia is a neuroleptic -induced condition invo lving the
face, trunk, and limbs. Involuntary movements, such as tongue
thrusting; licking; blowing; irregular movements of the arms, neck, and
shoulders; rocking; hip jerks; and pelvic thrusts, are seen. These
s ymptoms are frequentl y not reversible even w hen the drug is
discontinued. The scenario does not present evidence consistent with
the other disorders mentioned. Agranulocytosis is a blood disorder.
Tourettes syndrome is a condition in which tics are present.
Anticholinergic effects include dry mouth, blurred vision, flushing,
constipation, and dry eyes.
, PTS: 1 DIF: Cognitive Level: Anal yze (Anal ysis) REF: 206
TOP: Nursing Process: Evaluation MSC: Client Needs:
Physiological Integrity
2. A nurse sits with a patient diagnosed with schizophrenia. The pati ent
starts to laugh uncontrollabl y, although the nurse has not said anything
funny. Select the nurses best response.
a. Why are you laughing?
b. Please share the joke with me.
c. I dont think I said anything funny.
d. Youre laughing. Tell me whats happening.
ANS: D
The patient is likel y laughing in response to inner stimuli, such as
hallucinations or fantasy. Focus on the hallucinatory clue (the patients
laughter) and then elicit the patients observation. The incorrect options
are less useful in eliciting a response: no joke may be involved, why
questions are difficult to answer, and the patient is probabl y not
focusing on what the nurse said in the first place.
PTS: 1 DIF: Cognitive Level: Appl y (Application)
REF: 197 TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
3. The nurse assesses a patient diagnosed with schizophrenia. Which
assessment finding would the nurse regard as a negative symptom of
schizophrenia?
a. Auditory hallucinations
b. Delusions of grandeur
, c. Poor personal hygiene
d. Psychomotor agitation
ANS: C
Negative symptoms include apathy, anhedonia, poor social functioning,
and povert y of thought. Poor personal hygiene is an example of poor
social functioning. The distracters are positive symptoms of
schizophrenia. See relationship to audience response question.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
REF: 198 TOP: Nursing Process: Assessment MSC:
Client Needs: Psychosocial Integrit y
4. What assessment findings mark the prodromal stage of schizophrenia?
a. Withdrawal, misinterpreting, poor concentration, and preoccupation
with religion
b. Auditory hallucinations, ideas of reference, thought insertion, and
broadcasting
c. Stereot yped behavior, echopraxia, echolalia, and waxy flexibilit y
d. Loose associations, concr ete thinking, and echolalia neologisms
ANS: A
Withdrawal, misinterpreting, poor concentration, and preoccupation
with religion are prodromal symptoms, the symptoms that are present
before the development of florid symptoms. The incorrect options each
list the positive sym ptoms of schizophrenia that might be apparent
during the acute stage of the illness.
