When the session finally begins, the client expresses anger. Which response by the nurse would

NCLEX RN Mental Health and Psychiatric Nursing (Schizophrenia)

• A client with borderline personality disorder becomes angry when he is told that today’s

psychotherapy session with the nurse will be delayed 30 minutes because of an emergency.When the session finally begins, the client expresses anger. Which response by the nurse would be most helpful in dealing with the client’s anger?

• “If it had been your emergency, I would have made the other client wait.”
• “I know it’s frustrating to wait. I’m sorry this happened.”

• “You had to wait. Can we talk about how this is making you feel right now?”
• “I really care about you and I’ll never let this happen again.”

Correct Answer: C. “You had to wait. Can we talk about how this is making you feel right now?” This response may diffuse the client’s anger by helping to maintain a therapeutic relationship and addressing the client’s feelings. Regardless of the clinical setting, the nurse must provide structure and limit setting in the therapeutic relationship; in a clinic setting, this may mean seeing the client for scheduled appointments of a predetermined length rather than whenever the client appears and demands the nurse’s immediate attention.Option A: This wouldn’t address the client’s anger. Cognitive restructuring is a technique useful in changing patterns of thinking by helping clients to recognize negative thoughts and feelings and to replace them with positive patterns of thinking; thought stopping is a technique to alter the process of negative or self-critical thought patterns.Option B: This is incorrect because the client with a borderline personality disorder blames others for things that happen, so apologizing reinforces the client’s misconceptions. Establish boundaries in relationships. The nurse must be quite clear about establishing the boundaries of the therapeutic relationship to ensure that neither the client’s nor the nurse’s boundaries are violated.Option D: The nurse can’t promise that a delay will never occur again because such matters are outside the nurse’s control. Help clients to cope and to control emotions. The nurse can help the clients to identify their feelings and learn to tolerate them without exaggerated responses such as destruction of property or self-harm; keeping a journal often helps clients gain awareness of feelings.

• A 26-year-old client is admitted to the psychiatric unit with acute onset of schizophrenia. His

physician prescribes the phenothiazine chlorpromazine (Thorazine), 100 mg by mouth four times per day. Before administering the drug, the nurse reviews the client’s medication history.Concomitant use of which drug is likely to increase the risk of extrapyramidal effects?

• guanethidine (Ismelin)

• droperidol (Inapsine) 1 / 4

• lithium carbonate (Lithonate)
• Alcohol

Correct Answer: B. droperidol (Inapsine)

When administered with any phenothiazine, droperidol may increase the risk of extrapyramidal effects.Despite being a low-potency drug, chlorpromazine can still cause extrapyramidal side effects (EPS) such as acute dystonia, akathisia, parkinsonism, and tardive dyskinesia (TD). The evolution of EPS side effects can occur through hours to days. Acute dystonia refers to muscle stiffness or spasm of the head, neck, and eye muscles that can start hours after starting the medication. Akathisia includes restlessness and fast pacing. Parkinsonism includes bradykinesia, “cogwheel” rigidity, and shuffling gait.Option A: An antihypertensive agent that acts by inhibiting selectively transmission in postganglionic adrenergic nerves. It is believed to act mainly by preventing the release of norepinephrine at nerve endings and causes depletion of norepinephrine in peripheral sympathetic nerve terminals as well as in tissues.Option C: Lithium was the first mood stabilizer and is still the first-line treatment option, but is underutilized because it is an older drug. Lithium is a commonly prescribed drug for a manic episode in bipolar disorder as well as maintenance therapy of bipolar disorder in a patient with a history of a manic episode. The primary target symptoms of lithium are mania and unstable mood.Option D: Taking these products too close together may make this medicine less effective. This medicine will add to the effects of alcohol and other central nervous system (CNS) depressants (medicines that slow down the nervous system, possibly causing drowsiness).

• Since admission 4 days ago, a client has refused to take a shower, stating, “There are poison

crystals hidden in the showerhead. They’ll kill me if I take a shower.” Which nursing action is most appropriate?

• Dismantling the showerhead and showing the client that there is nothing in it.
• Explaining that other clients are complaining about the client’s body odor.
• Asking a security officer to assist in giving the client a shower.

• Accepting these fears and allowing the client to take a sponge bath.

Correct Answer: D. Accepting these fears and allowing the client to take a sponge bath By acknowledging the client’s fears, the nurse can arrange to meet the client’s hygiene needs in another way. Attempt to understand the significance of these beliefs to the client at the time of their presentation. Important clues to underlying fears and issues can be found in the client’s seemingly illogical fantasies. Recognize the client’s delusions as the client’s perception of the environment.Recognizing the client’s perception can help you understand the feelings he or she is experiencing.Option A: Because these fears are real to the client, providing a demonstration of reality wouldn’t be effective at this time. Interact with clients on the basis of things in the environment. Try to distract the client from their delusions by engaging in reality-based activities (e.g., card games, 2 / 4

simple arts and crafts projects etc). When thinking is focused on reality-based activities, the client is free of delusional thinking during that time. Helps focus attention externally.Option B: Initially do not argue with the client’s beliefs or try to convince the client that the delusions are false and unreal. Arguing will only increase a client’s defensive position, thereby reinforcing false beliefs. This will result in the client feeling even more isolated and misunderstood.• Option C: These would violate the client’s rights by shaming or embarrassing the client. Do not touch the client; use gestures carefully. Suspicious clients might misinterpret touch as either aggressive or sexual in nature and might interpret it as a threatening gesture. People who are psychotic need a lot of personal space.

• A client is admitted to the psychiatric hospital with a diagnosis of catatonic schizophrenia.

During the physical examination, the client’s arm remains outstretched after the nurse obtains the pulse and blood pressure, and the nurse must reposition the arm. This client is exhibiting:

• Waxy flexibility
• Negativity
• Suggestibility
• Retardation

Correct Answer: A. Waxy flexibility

Waxy flexibility, the ability to assume and maintain awkward or uncomfortable positions for long periods, is characteristic of catatonic schizophrenia. Clients commonly remain in these awkward positions until someone repositions them. Catatonic patients may also display “waxy flexibility”, meaning that they allow themselves to be moved into new positions, but do not move on their own.Most of the time, this is not an act or a show but rather a genuine and unpremeditated symptom of the illness that patients cannot help.Option B: Negativity, for example, is resistance to being moved or being asked to cooperate. This psychological phenomenon explains why bad first impressions can be so difficult to overcome and why past traumas can have such long lingering effects. In almost any interaction, we are more likely to notice negative things and later remember them more vividly.Option C: Clients with dependency problems may demonstrate suggestibility, a response pattern in which one easily agrees to the ideas and suggestions of others rather than making independent judgments. Suggestibility is the quality of being inclined to accept and act on the suggestions of others. One may fill in gaps in certain memories with false information given by another when recalling a scenario or moment. Suggestibility uses cues to distort recollection: when the subject has been persistently telling something about a past event, his or her memory of the event conforms to the repeated message.Option D: Retardation (slowed movement) also occurs in catatonic clients. Psychomotor retardation (PMR) is a possible feature of a melancholic depressive episode. It can include slowing of speech, 3 / 4

thinking, and body movements. Speech may also be decreased in volume or inflection, and there may be increased pauses to the extreme of mutism, which is also a symptom of catatonia.

• Every day for the past 2 weeks, a client with schizophrenia stands up during group therapy and

screams, “Get out of here right now! The elevator bombs are going to explode in 3 minutes!” The next time this happens, how should the nurse respond?

• “Why do you think there is a bomb in the elevator?”
• “That is the same thing you said in yesterday’s session.”

• “I know you think there are bombs in the elevator, but there aren’t.”
• “If you have something to say, you must do it according to our group rules.”

Correct Answer: C. “I know you think there are bombs in the elevator, but there aren’t.” This is the most therapeutic response because it orients the client to reality. Identify feelings related to delusions. If a client believes someone is going to harm him/her, the client is experiencing fear. When people believe that they are understood, anxiety might lessen.Option A: Interact with clients on the basis of things in the environment. Try to distract the client from their delusions by engaging in reality-based activities (e.g., card games, simple arts and crafts projects etc). When thinking is focused on reality-based activities, the client is free of delusional thinking during that time. Helps focus attention externally.Option B: These are condescending. Attempt to understand the significance of these beliefs to the client at the time of their presentation. Important clues to underlying fears and issues can be found in the client’s seemingly illogical fantasies. Recognize the client’s delusions as the client’s perception of the environment. Recognizing the client’s perception can help you understand the feelings he or she is experiencing.Option D: This sounds punitive and could embarrass the client. Initially do not argue with the client’s beliefs or try to convince the client that the delusions are false and unreal. Arguing will only increase a client’s defensive position, thereby reinforcing false beliefs. This will result in the client feeling even more isolated and misunderstood.

• The nurse formulates a nursing diagnosis of Impaired verbal communication for a client with

schizotypal personality disorder. Based on this nursing diagnosis, which nursing intervention is most appropriate?

• Helping the client to participate in social interactions.

• Establishing a one-on-one relationship with the client.
• Establishing alternative forms of communication.
• Allowing the client to decide when he wants to participate in verbal communication

with the nurse.Correct Answer: B. Establishing a one-on-one relationship with the client

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