Question 1

A client diagnosed with schizophrenia spectrum disorder tells a nurse about voices commanding him to kill the president. Which is the priority nursing diagnosis for this client?

Accepted Answer

The client's statement about hearing voices commanding him to commit a violent act indicates a risk for violence directed towards others. Therefore, the priority nursing diagnosis for this client is "risk for violence: directed towards others." While disturbed sensory perception and altered thought processes are also relevant nursing diagnoses for clients with schizophrenia, they are not the priority in this situation as the client's homicidal ideation presents an immediate risk to others. Risk for injury is a more general diagnosis and does not address the specific risk of violence towards others.

Question 2

A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be included in the nurse's teaching?

Accepted Answer

Social skills training involves teaching clients how to communicate effectively and appropriately, and making eye contact is an important component of this. Option A is important but not specific to social skills training. Option B may be helpful but is not specific to social skills training. Option D may not be appropriate for all clients and is not specific to social skills training.

Question 3

Order the spectrum of schizophrenic and other psychotic disorders as described by the DSM-5 on a gradient of psychopathology from least to most severe.
________ Delusional disorder
________ Schizotypal personality disorder
________ Schizophrenia
________ Brief psychotic disorder
________ Psychotic disorder associated with another medical condition
________ Catatonic disorder associated with another medical condition
________ Schizoaffective disorder
________ Schizophreniform disorder
________ Substance-induced psychotic disorder

Accepted Answer

The correct order is 2, 1, 9, 3, 5, 6, 8, 7, 4

Question 4

A client is diagnosed with schizophrenia spectrum disorder. 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?

Accepted Answer

Benztropine is an anticholinergic medication used to treat extrapyramidal side effects such as restlessness and muscle rigidity caused by haloperidol. It is not indicated for tactile hallucinations (A) or hearing disturbing voices (D). Tardive dyskinesia (B) is a potential side effect of long-term use of antipsychotic medications, but benztropine is typically used to treat acute extrapyramidal side effects.

Question 5

Which nursing intervention would be most appropriate when caring for an acutely agitated paranoid client diagnosed with schizophrenia spectrum disorder?

Accepted Answer

Providing personal space is the most appropriate nursing intervention when caring for an acutely agitated paranoid client with schizophrenia spectrum disorder. This intervention helps to respect the client's boundaries and reduces the risk of further agitating the client, which can lead to a potential altercation or physical harm. The other options may actually exacerbate the client's agitation, as neon lights and music may be overwhelming, maintaining continual eye contact can be seen as confrontational, and therapeutic touch may not be welcomed by a paranoid client.

Question 6

A 16-year-old client diagnosed with schizophrenia spectrum disorder experiences command hallucinations to harm others. The client's parents ask a nurse, "Where do the voices come from?" Which is the appropriate nursing response?

Accepted Answer

Option A is the most appropriate nursing response as it provides an accurate and understandable explanation of the client's condition. It also avoids placing blame on medication or hormones, which can add unnecessary distress for the parents.

Question 7

An aging client diagnosed with schizophrenia spectrum disorder takes an antipsychotic and a beta-adrenergic blocking agent for hypertension. Understanding the combined side effects of these drugs, which statement by a nurse is most appropriate?

Accepted Answer

The beta-adrenergic blocking agent can lead to orthostatic hypotension, which can be exacerbated by the antipsychotic medication. Instructing the client to rise slowly when changing position can prevent falls and dizziness. The other options are not specifically related to the side effects of these medications.

Question 8

___________________________ disorder is manifested by schizophrenic behaviors, with a strong element of symptomatology associated with the mood disorders (depression or mania).

Accepted Answer

The answer of ___________________________ disorder is manifested by schizophrenic behaviors,...

Question 9

A client has been assigned an admission diagnosis of brief psychotic disorder. Which assessment information would alert the nurse to question this diagnosis?

Accepted Answer

The answer of A client has been assigned an admission...

Question 10

The diagnosis of catatonic disorder associated with 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 of the following?

Accepted Answer

Catatonic disorder associated with another medical condition can be attributed to various medical conditions, including hyperthyroidism, hypothyroidism, hyperadrenalism, and hypoadrenalism, as these conditions can affect the nervous system and lead to catatonic symptoms. Hyperaphia is not a recognized medical condition.

Question 11

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?

Accepted Answer

The most appropriate nursing response is to acknowledge the client's perception but also to provide reassurance that the voices are not real and are a result of their illness. It is important not to dismiss or minimize the client's experience, but rather to validate their feelings while providing education about the nature of their symptoms. Option A is not appropriate as it could come across as confrontational or accusatory. Option B is not helpful as it does not address the client's concerns and could potentially reinforce their delusions. Option D is incorrect as it is not evidence-based and could be perceived as judgmental or dismissive of the client's experiences.

Question 12

A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client's safety?

Accepted Answer

The priority should be to note escalating behaviors and intervene immediately as safety is the most important concern. Bizarre behaviors, neologisms, and thought insertion can be symptoms of severe mental illness, and may increase the client's risk for harming themselves or others. Therefore, the nurse should monitor the client closely and intervene if they notice any signs of harm. Once safety is established, then the other options can be addressed.

Question 13

A client diagnosed with schizophrenia spectrum disorder is prescribed clozapine (Clozaril). Which client symptoms, related to the side effects of this medication, should prompt a nurse to intervene immediately?

Accepted Answer

Clozapine can cause agranulocytosis, a potentially life-threatening side effect characterized by a low white blood cell count. Symptoms of agranulocytosis include sore throat, fever, and malaise. This requires immediate intervention to prevent further complications. Akathisia, hypersalivation, akinesia, insomnia, dry mouth, and urinary retention are potential side effects of clozapine but are not as urgent as agranulocytosis.

Question 14

Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia spectrum disorder?

Accepted Answer

Being reliable, honest, and consistent during interactions is important in establishing trust with clients diagnosed with schizophrenia spectrum disorder. These individuals often have difficulty trusting others and may have a history of being mistreated or stigmatized by healthcare providers. By consistently demonstrating reliability and honesty, nurses can help to build trust and establish a therapeutic relationship. Establishing personal contact with family members may be important for care coordination, but it is not necessarily related to building trust with the client. Sharing personal information is not recommended, as it can blur professional boundaries and compromise objectivity. Sitting close to the client may be appropriate in some situations, but it is not necessarily related to building trust.

Question 15

A nurse is assessing a client diagnosed with substance induced psychotic disorder (SIPD). What would differentiate this client's symptoms from the symptoms of a client diagnosed with brief psychotic disorder (BPD)?

Accepted Answer

The presence of catatonic features is associated with SIPD, but not BPD. While both disorders may involve delusions and hallucinations, the presence of catatonic features would differentiate SIPD from BPD.

Question 16

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?

Accepted Answer

Positive symptoms of schizophrenia are those that involve the presence of abnormal behavior, such as delusions, hallucinations, and disorganized speech. Paranoid delusions, neologisms, and echolalia are all positive symptoms. Negative symptoms, on the other hand, involve the absence of normal behavior, such as lack of motivation or emotional expression. Anhedonia, anergia, and flat affect are all negative symptoms.

Question 17

A paranoid client diagnosed with schizophrenia spectrum disorder 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?

Accepted Answer

The client is exhibiting command hallucinations, which are a type of auditory hallucination in which the individual hears a voice that commands them to do something. In this case, the voice is telling the client to stop their psychiatrist. The nurse's legal responsibility is to warn the psychiatrist about the client's statements and the possibility of harm. This ensures that the psychiatrist can take necessary precautions and protective measures.

Question 18

Parents ask a nurse how they should reply when their child, diagnosed with schizophrenia spectrum disorder, tells them that voices command him to harm others. Which is the appropriate nursing response?

Accepted Answer

The nurse should focus on the patient's feelings and present reality rather than denying the existence of the voices or ignoring the situation. Encouraging the patient to express how the voices make them feel and grounding them in the present moment can help the patient cope with the hallucinations and reduce their potential for harmful behavior. Telling the patient to stop discussing the voices (answer A) may create feelings of shame, and ignoring the situation (answer B) may allow the hallucinations to continue without intervention. Presenting objective evidence that the voices are not real (answer D) may also create feelings of shame and invalidate the patient's experiences.

Question 19

Which of the following components should a nurse recognize as an integral part of a rehabilitative program when planning care for clients diagnosed with schizophrenia spectrum disorder?

Accepted Answer

Group therapy, medication management, supportive family therapy, and social skills training are all integral parts of a rehabilitative program for clients diagnosed with schizophrenia spectrum disorder. Deterrent therapy is not a recognized component of schizophrenia treatment.

Question 20

A nurse is assessing a client diagnosed with schizophrenia spectrum disorder. The nurse asks the client, "Do you receive special messages from certain sources, such as the television or radio?" The nurse is assessing which potential symptom of this disorder?

Accepted Answer

Delusions of reference involve the belief that ordinary events, objects, or behaviors of others have particular and unusual meanings that are specific to the individual. This can include the belief that external sources such as the media are sending messages to them directly. Thought insertion involves the belief that one's thoughts are not their own, paranoid delusions involve a belief that others are out to harm them, and magical thinking involves the belief that one's thoughts, words, or actions have the power to influence events.

Quiz 15: Schizophrenia Spectrum and Other Psychotic Disorders