NUR410 Wk 4 Schizophrenia NCLEX questions

NUR410 Wk 4 Schizophrenia NCLEX questions

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• A paranoid client presents with bizarre behaviors, neologisms, and

thought insertion. Which nursing action should be prioritized to maintain this client's safety?

• Assess for medication noncompliance
• Note escalating behaviors and intervene immediately
• Interpret attempts at communication
• Assess triggers for bizarre, inappropriate behaviors: ANS: B

The nurse should note escalating behaviors and intervene immediately to maintain this client's safety. Early intervention may prevent an aggressive response and keep the client and others safe.

• A client diagnosed with schizoaffective disorder is admitted for social

skills training. Which information should be taught by the nurse?

• The side effects of medications
• Deep breathing techniques to decrease stress
• How to make eye contact when communicating
• How to be a leader: ANS: C

The nurse should plan to teach the client how to make eye contact when commu- nicating. Social skills, such as making eye contact, can assist clients in communi- cating needs and maintaining connectedness.

• A 16-year-old-client diagnosed with paranoid schizophrenia experiences

command hallucinations to harm others. The client's parents ask a nurse, "Where do the voices come from?" Which is the appropriate nursing reply?

• "Your child has a chemical imbalance of the brain which leads to altered

thoughts."

• "Your child's hallucinations are caused by medication interactions."
• "Your child has too little serotonin in the brain causing delusions and

hallucinations."

• "Your child's abnormal hormonal changes have precipitated auditory

hallucinations.": ANS: A 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.

• Parents ask a nurse how they should reply when their child, diagnosed

with paranoid schizophrenia, tells them that voices command him to harm others. Which is the appropriate nursing reply?

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• "Tell him to stop discussing the voices."
• "Ignore what he is saying, while attempting to discover the underlying

cause."

• "Focus on the feelings generated by the hallucinations and present reali-

ty."

• "Present objective evidence that the voices are not real.": ANS: C

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.

• A nurse is assessing a client diagnosed with paranoid 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?

• Thought insertion
• Paranoid delusions
• Magical thinking
• Delusions of reference: ANS: D

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.

• 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 client's statement?

• "The client is experiencing command hallucinations."
• "The client is expressing a neologism."
• "The client is experiencing a paranoid delusion."
• "The client is verbalizing a word salad.": ANS: B

The nurse should describe the client's 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. Word salad refers to a group of words that are put together randomly.

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• During an admission assessment, a nurse asks a client diagnosed with

schizophrenia, "Have you ever felt that certain objects or persons have con- trol over your behavior?" The nurse is assessing for which type of thought disruption?

• Delusions of persecution
• Delusions of influence
• Delusions of reference
• Delusions of grandeur: ANS: B

The nurse is assessing the client for delusions of influence when asking if the client has ever felt that objects or persons have control of the client's behavior.Delusions of control or influence are manifested when the client believes that his or her behavior is being influenced. An example would be if a client believes that a hearing aid receives transmissions that control personal thoughts and behaviors.

• A client diagnosed with schizophrenia 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 reply?

• "Did you take your medicine this morning?"
• "You are not going to hell. You are a good person."
• "I'm sure the voices sound scary. The devil is not talking to you. This is

part of your illness."

• "The devil only talks to people who are receptive to his influence.": ANS:

C The most appropriate reply by the nurse is to reassure the client with an accepting attitude while not reinforcing the hallucination. Reminding the client that "the voices" are a part of his or her illness is a way to help the client accept that the hallucinations are not real.

• 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?

• Disturbed sensory perception
• Altered thought processes

C. Risk for violence: directed toward others

• Risk for injury: 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

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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?

• Provide neon lights and soft music.
• Maintain continual eye contact throughout the interview.
• Use therapeutic touch to increase trust and rapport.
• Provide personal space to respect the client's boundaries.: 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?

• Establishing personal contact with family members.
• Being reliable, honest, and consistent during interactions.
• Sharing limited personal information.
• Sitting close to the client to establish rapport.: ANS: B

The nurse can enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia by being reliable, honest, and consistent during interactions. The nurse should also convey acceptance of the client's needs and maintain a calm attitude when dealing with agitated behavior.

• A client diagnosed with paranoid schizophrenia states, "My psychiatrist

is out to get me. I'm sad that the voice is telling me to stop him." What symptom is the client exhibiting, and what is the nurse's legal responsibility related to this symptom?

• Magical thinking; administer an antipsychotic medication
• Persecutory delusions; orient the client to reality
• Command hallucinations; warn the psychiatrist

D. Altered thought processes; call an emergency treatment team meeting: -

ANS: C

The nurse should determine that the client is exhibiting command hallucinations.The nurse's legal responsibility is to warn the psychiatrist of the potential for harm. A client who is demonstrating a risk for violence could potentially become physically, emotionally, and/or sexually harmful to others or to self.