A well-known client suffers a psychotic break and is admitted to
the psychiatric unit. A large group of reporters with cameras is
camped out in the
... [Show More] hospital parking lot. As a nurse walks to the
employee parking after her shift, a reporter asks if she knows
anything about the client's conditio
Question 1 See full question
A client with schizophrenia repeatedly uses profanity during an activity therapy session. Which response
by the nurse is appropriate?
You Selected:
"Your behavior won't be tolerated. Go to your room immediately."
Correct response:
"Your cursing is interrupting the activity. Take time out in your room for 10 minutes."
Explanation:
Remediation:
Question 2 See full question
When conducting a mental status examination with a newly admitted client who has a diagnosis of
paranoid schizophrenia, the client states, “I am being followed; it is not safe. They are monitoring my
every move.” In which area of the mental status examination should the nurse document this information?
You Selected:
insight
Correct response:
thought content
Explanation:
Question 1 See full question
A client with delusional thinking who is overweight and tends to eat when
stressed shows a lack of interest in eating at meal times. She states that she
is unworthy of eating and that her children will die if she eats. Which nursing
action is most appropriate for this client?
You Selected:
Paying special attention to the client's meal-related rituals and
emotions
Correct response:
Restricting the client's access to food except at specified meal and
snack times
Explanation:
Remediation:
Question 2 See full question
A client is about to be discharged with a prescription for the antipsychotic
agent haloperidol, 10 mg by mouth twice per day. During a discharge
teaching session, a nurse should provide which instruction to the client?
You Selected:
Apply a sunscreen before exposure to the sun.
Correct response:
Apply a sunscreen before exposure to the sun.
Explanation:
Remediation:
Question 3 See full question
A client has been receiving chlorpromazine, an antipsychotic, to treat his
psychosis. Which findings should alert the nurse that the client is
experiencing pseudoparkinsonism?
You Selected:
Tremors, shuffling gait, and masklike face
Correct response:
Tremors, shuffling gait, and masklike face
Explanation:
Remediation:
Question 4 See full question
Which response demonstrates that the parents of a child with newly
diagnosed schizophrenia understand their child's diagnosis?
You Selected:
"We'll watch him swallow his daily pills and call the physician if he
doesn't."
Correct response:
"We'll watch him swallow his daily pills and call the physician if he
doesn't."
Explanation:
Remediation:
Question 5 See full question
During a home visit for a client diagnosed with paranoid schizophrenia
discharged 1 week ago, the client’s mother tearfully states, “I can hardly
sleep because I am so worried about my daughter. I am afraid to leave her
alone in the house. What if something should happen while I am gone?”
Which caregiver problem would be the most inclusive one for the nurse to
incorporate into the client’s plan of care?
You Selected:
disturbed sleep pattern
Correct response:
caregiver role strain
Explanation:
Remediation:
Question 6 See full question
An outpatient client who has a history of paranoid schizophrenia and chronic
alcohol dependency has been taking risperidone for several months. She
reports that she stopped drinking 4 days ago. The client is very frightened by
the tactile hallucinations of bugs crawling under her skin. Which factor
should the nurse incorporate into the plan of care when explaining the tactile
hallucinations?
You Selected:
alcohol withdrawal
Correct response:
alcohol withdrawal
Explanation:
Remediation:
Question 7 See full question
The client with a diagnosis of schizophrenia spends much of the morning in
the bedroom but seeks out the nurse for brief interactions throughout the
morning. Which goal should the nurse assist the client with achieving in the
afternoon? The client will:
You Selected:
engage three of his peers in a card game.
Correct response:
help put a puzzle together.
Explanation:
Remediation:
Question 8 See full question
The client with a diagnosis of schizophrenia walks into group naked. The
nurse should:
You Selected:
lead the client to his room and help him dress if he needs assistance.
Correct response:
lead the client to his room and help him dress if he needs assistance.
Explanation:
Remediation:
Question 9 See full question
One of the clients in group with a dual diagnosis of chronic schizophrenia and
alcohol abuse states, “I am not going to take medicine every day.” Which
response by the nurse would be mostappropriate?
You Selected:
“I hear you say that you do not like taking medication daily.”
Correct response:
“I hear you say that you do not like taking medication daily.”
Explanation:
Remediation:
Question 10 See full question
While planning the care for a client with paranoid delusions, which of the
following will be the nurse’s initial goal for the client?
You Selected:
Establish trust with staff.
Correct response:
Establish trust with staff.
Explanation:
Remediation:
Question 3 See full question
One of the clients in group with a dual diagnosis of chronic schizophrenia and alcohol abuse states, “I am
not going to take medicine every day.” Which response by the nurse would be mostappropriate?
You Selected:
“Let us discuss this tomorrow if we have time.”
Correct response:
“I hear you say that you do not like taking medication daily.”
Explanation:
Remediation:
Question 4 See full question
The client tells the nurse that she stopped taking olanzapine 2 weeks ago because she is better and wants
“to make it on my own without this darned medicine.” What would be the nurse’s mosttherapeutic
response?
You Selected:
“You have told me about other times like this when you stopped taking your medication and you
got sick again. You should know better by now.”
Correct response:
”I know you get tired of taking the medication, especially when you are doing well. Is there any
special reason you decided to stop right now?”
Explanation:
Remediation:
Question 5 See full question
The guardian of a client diagnosed with schizophrenia indicates to the nurse a concern that the client is at
risk for suicide. Which question to the client would the nurse utilize to determine the seriousness of the
suicidal idealization?
You Selected:
“Are you planning on hurting yourself?”
Correct response:
Question 1 See full question
A client who takes neuroleptic medication for treatment of chronic schizophrenia is admitted to the
psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, and diaphoresis. Which lifethreatening reaction do these findings suggest?
You Selected:
Neuroleptic malignant syndrome
Correct response:
Neuroleptic malignant syndrome
Explanation:
Remediation:
Question 2 See full question
A client with a diagnosis of borderline personality disorder is admitted to the psychiatric unit. The nurse
expects the assessment to reveal:
You Selected:
coldness, detachment, and lack of tender feelings.
Correct response:
unpredictable behavior and intense interpersonal relationships.
Explanation:
A client with borderline personality disorder displays a pervasive pattern of unpredictable behavior,
mood, and self-image. His interpersonal relationships may be intense and unstable, and his behavior may
be inappropriate and impulsive. Although the client's impaired ability to form relationships may affect his
parenting skills, his inability to function as a responsible parent is more typical of antisocial personality
disorder. Somatic symptoms characterize avoidant personality disorder. Coldness, detachment, and lack
of tender feelings typify schizoid and schizotypal personality disorders.
Remediation:
Question 3 See full question
A client with a tentative diagnosis of psychosis is admitted to the psychiatric unit. A physician orders the
phenothiazine thioridazine 50 mg by mouth three times per day. Phenothiazines differ from central
nervous system (CNS) depressants in their sedative effects by producing:
You Selected:
more prolonged sedative effects, making the client more difficult to arouse.
Correct response:
a calming effect from which the client is easily aroused.
Explanation:
Remediation:
Question 4 See full question
A nurse is teaching a psychiatric client about his ordered drugs, chlorpromazine and benztropine. What
evaluation would indicate a therapeutic response to these drugs?
You Selected:
The client expresses a decrease in anxiety.
Correct response:
The client is experiencing less psychosis and a decrease in extrapyramidal symptoms.
Explanation:
Benztropine is an anticholinergic medication administered to reduce the extrapyramidal adverse effects
of chlorpromazine and other antipsychotic medications. Benztropine doesn't reduce psychotic
symptoms, relieve anxiety, or control nausea and vomiting. If the client displays akathisia or meaningless
movements, this is not a therapeutic effect of the medication.
Remediation:
Question 5 See full question
The client with borderline personality disorder spends much time around the nurse's station, making
numerous minor requests. The nurse interprets these behaviors as indicating which factor?
You Selected:
fears of abandonment and attention seeking
Correct response:
fears of abandonment and attention seeking
Explanation:
Remediation:
Question 6 See full question
A nurse is planning care for a regressed, chronically ill client diagnosed with schizophrenia. What is
the most appropriate milieu?
You Selected:
nurturance and supportive interaction focusing on individual needs
Correct response:
nurturance and supportive interaction focusing on individual needs
Explanation:
Remediation:
Question 1 See full question
A client with schizophrenia is admitted to the psychiatric unit of a local
hospital. During the next several days, the client is seen laughing, yelling,
and talking to himself. This behavior is characteristic of:
You Selected:
hallucination.
Correct response:
hallucination.
Explanation:
Remediation:
Question 2 See full question
A well-known client suffers a psychotic break and is admitted to the
psychiatric unit. A large group of reporters with cameras is camped out in the
hospital parking lot. As a nurse walks to the employee parking after her shift,
a reporter asks if she knows anything about the client's condition. What is
the most appropriate response?
You Selected:
"All I can say is that the client is safe and stable."
Correct response:
"I can't answer your question."
Explanation:
Question 3 See full question
Which response demonstrates that the parents of a child with newly
diagnosed schizophrenia understand their child's diagnosis?
You Selected:
"As long as we're understanding and supportive, he'll eventually be fine."
Correct response:
"We'll watch him swallow his daily pills and call the physician if he doesn't."
Explanation:
Remediation:
Question 4 See full question
A nurse is planning care for a regressed, chronically ill client diagnosed with
schizophrenia. What is the most appropriate milieu?
You Selected:
nurturance and supportive interaction focusing on individual needs
Correct response:
nurturance and supportive interaction focusing on individual needs
Explanation:
Remediation:
Question 5 See full question
During a home visit, a client who is 75 years of age tells the community
health nurse, “Lately I am getting forgetful about things. For one thing, I
cannot remember names. Do you think I am getting Alzheimer’s disease?”
Which response by the nurse is the most therapeutic?
You Selected:
“Most people your age have this problem. It is not Alzheimer’s disease.”
Correct response:
“Tell me more about your forgetfulness. It is not unusual for forgetfulness to
occur.”
Explanation:
A client with schizophrenia states, "I hear the voice of King Tut." Which
response by the nurse is therapeutic?
You Selected:
"I don't hear the voice, but I know you hear what sounds like a voice."
Correct response:
"I don't hear the voice, but I know you hear what sounds like a voice."
Explanation:
Remediation:
Question 2 See full question
A client with a diagnosis of borderline personality disorder is admitted to the
psychiatric unit. The nurse expects the assessment to reveal:
You Selected:
unpredictable behavior and intense interpersonal relationships.
Correct response:
unpredictable behavior and intense interpersonal relationships.
Explanation:
Remediation:
Question 3 See full question
A client begins clozapine therapy after several other antipsychotic agents fail
to relieve her psychotic symptoms. The nurse instructs her to return for
weekly white blood cell (WBC) counts to assess for which adverse reaction?
You Selected:
Granulocytopenia
Correct response:
Granulocytopenia
Explanation:
Remediation:
Question 4 See full question
While pacing in the hall, a client with schizophrenia runs to a nurse and asks,
"Why are you poisoning me? I know you work for Central Thought Control!
You can keep my thoughts. Give me back my soul!" How should the nurse
respond during the early stage of the therapeutic process?
You Selected:
"I'm a nurse, and you're a client in the hospital. I'm not going to harm you."
Correct response:
"I'm a nurse, and you're a client in the hospital. I'm not going to harm you."
Explanation:
Remediation:
Question 5 See full question
A client diagnosed with borderline personality disorder has self-inflicted cuts
on her arms. The nurse is assessing the client for the risk of suicide. What
should the nurse ask the client first?
You Selected:
if she has a suicide plan
Correct response:
if she has a suicide plan
Explanation:
Remediation:
Question 6 See full question
A client diagnosed with schizophrenia is being switched to risperidone longacting injection. He is told that he will remain on his oral dose of risperidone
daily for approximately 1 month. The client says, "I did not have to take pills
when I was on fluphenazine shots in the past." The nurse should tell the
client:
You Selected:
"Risperidone long-acting injection initially takes a little longer to reach the
ideal blood level."
Correct response:
"Risperidone long-acting injection initially takes a little longer to reach the
ideal blood level."
Explanation:
Remediation:
Question 7 See full question
A client has been perceiving her roommate's stuffed animal as her own dog
at home. The nurse determines that this misperception of reality (illusion) is
improving when the client makes which statement? [Show Less]