Chapter 13: Schizophrenia and Other Psychotic Disorders My Nursing Test Banks

Fortinash: Psychiatric Mental Health Nursing, 5th Edition

Chapter 13: Schizophrenia and Other Psychotic Disorders

Test Bank

MULTIPLE CHOICE

1. A newly admitted patient has the diagnosis of catatonic schizophrenia. Which behavior observed in the patient supports that diagnosis?

a.

Uses a rhyming form of speech

b.

Refuses to eat any unwrapped foods

c.

Laughs when watching a sad movie

d.

Maintains an immobilized state for hours

ANS: D

Catatonic schizophrenia is characterized by extremes of psychomotor activity ranging from frenzied behavior to immobilization and may include echopraxia and posturing. Paranoid thinking is characteristic of paranoid schizophrenia. Inappropriate affect and clanging are seen in disorganized schizophrenia.

DIF: Cognitive Level: Application REF: Page 274

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

2. What would be an appropriate short-term outcome for a patient diagnosed with residual schizophrenia who exhibits ambivalence?

a.

Decide their own daily schedule.

b.

Decide which unit groups they will attend.

c.

Choose which clinic staff member to work with.

d.

Choose between two outfits to wear each morning.

ANS: D

An early step would be to make choices about nonthreatening matters when presented with limited alternatives. The remaining options represent decisions that are too complicated for the patient to make initially.

DIF: Cognitive Level: Application REF: Page 285

TOP: Nursing Process: Outcome Identification

MSC: NCLEX: Psychosocial Integrity

3. What is the priority nursing diagnosis for a catatonic patient?

a.

Ineffective coping

b.

Impaired physical mobility

c.

Impaired social interaction

d.

Risk for deficient fluid volume

ANS: D

The highest priority for the patient is maintenance of basic physiologic needs, such as hydration. Mobility is of lesser physiological importance than fluid volume. The remaining options do not have priority over a physiological need.

DIF: Cognitive Level: Application REF: Page 275 TOP: Nursing Process: Diagnosis

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

4. Which nursing diagnosis is appropriate for a patient who insists being called Your Highness and demonstrates loosely associated thoughts?

a.

Risk for violence

b.

Defensive coping

c.

Impaired memory

d.

Disturbed thought processes

ANS: D

Delusions and loose associations suggest disturbed thought processes. The other options are not supported by data in the scenario.

DIF: Cognitive Level: Application REF: Page 278 TOP: Nursing Process: Diagnosis

MSC: NCLEX: Psychosocial Integrity

5. Which initial short-term outcome would be appropriate for a patient who was admitted expressing delusional thoughts?

a.

Accept that delusion is illogical.

b.

Distinguish external boundaries.

c.

Explain the basis for the delusions.

d.

Engage in reality-oriented conversation.

ANS: D

Delusions are not reality oriented; thus an appropriate outcome would be that patient will engage in reality-oriented conversation rather than discussing delusional beliefs. Delusions are fixed, false beliefs. Patients rarely accept anyone using logic to dispute them. Data are not present to suggest boundary disturbance. Explaining the delusion is not progress; it suggests the patient still holds to the belief.

DIF: Cognitive Level: Application REF: Page 286

TOP: Nursing Process: Outcome Identification

MSC: NCLEX: Psychosocial Integrity

6. Which of the following interventions should the nurse plan to use to reduce patient focus on delusional thinking?

a.

Confronting the delusion

b.

Refuting the delusion with logic

c.

Exploring reasons the patient has the delusion

d.

Focusing on feelings suggested by the delusion

ANS: D

Focusing on feelings suggested by the delusion will help meet patient needs and help the patient stay based in reality. This technique fosters rapport and trust while discouraging the belief without challenging or refuting it.

DIF: Cognitive Level: Application REF: Page 286 TOP: Nursing Process: Planning

MSC: NCLEX: Psychosocial Integrity

7. Which assessment observation supports a patients diagnosis of disorganized schizophrenia?

a.

Reports suicidal ideations

b.

Last relapse was 6 years ago

c.

Consistent inappropriate laughing

d.

Believes that the government is out to get me

ANS: C

The presence of disorganization and inappropriate affect identifies this disorder as disorganized schizophrenia. The symptoms of residual schizophrenia have long periods of remission. Schizoaffective disorder presents with severe mood disorders along with symptoms of schizophrenia. Paranoid schizophrenia is characterized by persecutory or grandiose delusions.

DIF: Cognitive Level: Application REF: Page 274

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

8. A patient tried to gouge out his eye in response to auditory hallucinations commanding, If thine eye offends thee, pluck it out. The nurse would analyze this behavior as indicating:

a.

Derealization

b.

Inappropriate affect

c.

Impaired impulse control

d.

Inability to manage anger

ANS: C

Command hallucinations may be so intense that the patient cannot control the impulse to do what the hallucination tells him to do; thus the patient has impaired impulse control. This is not an anger management problem. Derealization is a feeling that the environment is distorted or unreal and not suggested in the scenario. No evidence of inappropriate affect is given.

DIF: Cognitive Level: Application REF: Page 278

TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

9. An appropriate intervention for a patient with an identified nursing diagnosis of situational low self-esteem would be:

a.

Providing large muscle activities to relieve stress

b.

Attempting to determine triggers to hallucinations

c.

Engaging patient in activities designed to permit success

d.

Encouraging verbalization of feelings in a safe environment

ANS: C

All are useful interventions for a patient with schizophrenia; however, engaging the patient in specifically designed activities is the only option that addresses improving self-esteem.

DIF: Cognitive Level: Application REF: Page 285

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

10. A 19-year-old patient is admitted for the second time in 9 months and is acutely psychotic with a diagnosis of undifferentiated schizophrenia. The patient sits alone rubbing her arms and smiling. She tells the nurse her thoughts cause earthquakes and that the world is burning. The nurse assesses the primary deficit associated with the patients condition as:

a.

Social isolation

b.

Disturbed thinking

c.

Altered mood states

d.

Poor impulse control

ANS: B

The nurse interprets the patients statements that were not reality-based as indicating disturbed thought processes. Social isolation is not the primary patient problem. No data exist to support the other options.

DIF: Cognitive Level: Application REF: Pages 278-279

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity

11. A patient has been admitted with disorganized type schizophrenia. The nurse observes blunted affect and social isolation. He occasionally curses or calls another patient a jerk without provocation. The nurse asks the patient how he is feeling, and he responds, Everybody picks on me. They frobitz me. The patients communication exhibits:

a.

A neologism

b.

Loose associations

c.

Delusional thinking

d.

Circumstantial speech

ANS: A

A newly coined word having meaning only for the patient is called a neologism (meaning, new word). It is associated with autistic thinking. The patients speech does not show associative looseness or circumstantiality. The use of a neologism is not delusional in and of itself, but it suggests delusional thinking may be present.

DIF: Cognitive Level: Comprehension REF: Page 278

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

12. A patient has been admitted with disorganized type schizophrenia. The nurse asks the patient how he is feeling, and he responds, Everybody picks on me. They frobitz me. The best response for the nurse to make would be:

a.

Thats really too bad that you are being treated that way.

b.

Who do you mean when you say everybody?

c.

What difference does frobitzing make?

d.

Why do they frobitz?

ANS: B

This response will help clarify the patients thinking and change the focus from global to specific. In this situation, sympathizing with the patient is a nonproductive response. The remaining options appear to accept the neologism thus supporting the patients delusional thinking.

DIF: Cognitive Level: Application REF: Page 286

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

13. Which patient behavior would support the diagnosis of residual schizophrenia with negative symptoms?

a.

Communicating using only rhyming phases

b.

Claims that worms are crawling in my brain

c.

Maintaining both arms suspended awkwardly overhead

d.

Shows no emotion when telling the story of a sisters recent death

ANS: D

Blunted affect is considered a negative symptom. The other symptoms would be classified as positive symptoms.

DIF: Cognitive Level: Application REF: Page 274 | Page 280

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

14. By discharge, which outcome is appropriate for a patient who hears voices telling him he is evil?

a.

Respond verbally to the voices.

b.

Verbalize the reason the voices say he is evil.

c.

Identify events that increase anxiety and promote hallucinations.

d.

Integrate the voices into his personality structure in a positive manner.

ANS: C

An appropriate outcome for a patient with hallucinations is recognition of events that precede the onset of hallucinations. Trigger events or situations usually cause increased feelings of anxiety. The remaining options are neither desirable nor appropriate.

DIF: Cognitive Level: Application REF: Page 277

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

15. Which response by the nurse would best assist a patient in de-escalating aggressive behavior?

a.

Tell me whats going on.

b.

Why are you getting so upset?

c.

If you throw something, you will be restrained.

d.

Its time for group therapy. You can talk there.

ANS: A

Using how, what, and when to gather information is a nonthreatening approach. It will promote patient verbalization and explanation of events without causing the patient to become defensive. Mentioning restraints sounds threatening even though it may be meant to remind the patient of limits. Why questions are demanding and threatening to patients. Sending the patient into group therapy sidesteps the problem.

DIF: Cognitive Level: Application REF: Pages 292-293

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

16. A 34-year-old male admitted with catatonic schizophrenia has been mute and motionless for several days while at home prior to admission. He still appears stuporous in the hospital. Which nursing intervention would be an initial priority?

a.

Orienting the patient to the unit

b.

Reinforcing reality with the patient

c.

Establishing a nonthreatening relationship

d.

Assessing the patient for physical problems

ANS: D

Patients who are mute and motionless and inattentive to environmental stimuli are at risk for a number of physical problems. Further, they are unable to communicate existing problems. The nurse must make thorough and astute assessments before creating plans to meet the patients needs. A patient who is stuporous may not be able to attend to information given about unit rules and protocols. While establishing a therapeutic nurse-patient relationship is an important intervention, it does not have priority according to Maslows hierarchy. Because the patient is mute, one can only suspect lack of reality orientation. While an appropriate intervention, it is not the priority according to Maslows hierarchy.

DIF: Cognitive Level: Application REF: Page 275

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

17. Which response is appropriate when a patients mother expresses guilt over causing my child to be schizophrenic?

a.

I can see how you would be upset over this turn of events.

b.

New findings suggest this disorder is biological in nature.

c.

Dont be so hard on yourself; your daughter needs you to be strong.

d.

Its difficult to see what produces stress for the child at the time its occurring.

ANS: B

Many individuals in the mental health field attribute the development of schizophrenia to multiple causes centering on biological theories. The remaining options do little to provide the mother with new information.

DIF: Cognitive Level: Application REF: Page 265

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

18. Which response demonstrates both empathy and understanding of the relationship genetics has to the development of schizophrenia in twins?

a.

In fraternal twins, the chance of the other twin developing the disorder is quite small.

b.

Studies show that 50% of twins develop schizophrenia when it is present in the other twin.

c.

No one can say what will happen, so we will hope for the best for you and both of your sons.

d.

You poor woman! I wish I could tell you that your other son he will be free of the disorder.

ANS: A

Current research supports the correct option, whereas the remaining options are not factual and show expressed sympathy rather than empathy.

DIF: Cognitive Level: Application REF: Page 266

TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

19. The wife of a patient diagnosed with paranoid schizophrenia asks, Ive been told that my husbands illness is probably related to imbalanced brain chemicals. Can you be more specific? The response based on the dopamine hypothesis is:

a.

Breakdown of dopamine produces LSD, which in large amounts produces psychosis.

b.

An increase in the brain chemical dopamine explains the presence of delusions and hallucinations.

c.

Decreased amounts of the brain chemical dopamine explain the presence of delusions and hallucinations.

d.

An increase in the brain chemical dopamine explains the presence of lack of motivation and disordered affect.

ANS: B

The statement is correctly based on the dopamine hypotheses while the remaining options are neither known to be true nor based on that theory

DIF: Cognitive Level: Comprehension REF: Page 266

TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

20. What is the basis for the reduction in disturbed thought processes when a patient is administered haloperidol (Haldol)?

a.

Reduction in the number of brain cells that crave dopamine

b.

Dopamine receptors are blocked, making dopamine less available

c.

Dopamine receptors are enhanced, making more dopamine available

d.

Medication causes an increased cellular production of dopamine

ANS: B

Excess dopamine is responsible for symptoms of psychosis such as delusions and hallucinations. Blocking dopamine receptors will result in reduction of primary symptoms. The other options do not reflect the action of typical antipsychotic medications.

DIF: Cognitive Level: Comprehension REF: Page 266

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

21. During a treatment team meeting, the point is made that a patient with schizophrenia has recovered from the acute psychosis but continues to demonstrate apathy, avolition, and blunted affect. The nurse who relates these symptoms to serotonin (5HT2) excess will suggest that the patient receive:

a.

Haloperidol (Haldol)

b.

Chlorpromazine (Thorazine)

c.

Olanzapine (Zyprexa)

d.

Phenelzine (Nardil)

ANS: C

Olanzapine is an atypical antipsychotic. Atypical antipsychotic medications are more effective than typical antipsychotics in blocking serotonin receptors and reducing the negative symptoms of schizophrenia. Haloperidol (Haldol) and chlorpromazine (Thorazine) are typical antipsychotic medications while phenelzine (Nardil) is an MAOI antidepressant.

DIF: Cognitive Level: Application REF: Page 287 | Page 289

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

22. What response would be anticipated when a patient who received chlorpromazine (Thorazine) for 15 years to treat schizophrenia is switched to Seroquel (quetiapine)?

a.

Development of pseudoparkinsonism

b.

Development of dystonic reactions

c.

Improvement in tardive dyskinesia

d.

Worsening of anticholinergic symptoms

ANS: C

Atypical antipsychotics have been noted to block oral dyskinesia and improve tardive dyskinesia as well as improve both positive and negative symptoms of schizophrenia. Pseudoparkinsonism and dystonic reactions are associated with typical antipsychotic medication. Anticholinergic symptoms are not intense with the use of atypical antipsychotic medication.

DIF: Cognitive Level: Application REF: Page 287 |Page 289

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

23. A patient admitted with the diagnosis of schizophreniform disorder R/O organic pathology. Based on this information, the nurse can expect that the patient will:

a.

Be scheduled for a magnetic resonance imaging (MRI) test

b.

See a mental health specialist for extensive psychological testing

c.

Have an immunologic assay performed within 2 days of the admission

d.

Participate in a dexamethasone suppression test (DST) administered by the staff

ANS: A

The MRI will reveal structural changes in the brain that might be responsible for symptoms of psychosis (e.g., abscess, tumor). Psychologic testing may be performed but will be less definitive in ruling out organic pathology. Immunologic studies are not indicated. The DST is related to depression.

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24. In planning aftercare for a patient with schizophrenia and whose insurance benefits have been exhausted, the nurse who is concerned about overcoming negative symptoms will make provisions for the patient to have stimulation, structure, socialization, and support. Which option would best incorporate these factors?

a.

Day hospitalization

b.

Attending a psychosocial club

c.

Living with his elderly mother

d.

Spending free time in the mall

ANS: B

A psychosocial club is organized to provide the 4 Ss and is not costly to patients. Day hospitalization would not be possible because of the lack of insurance benefits. Living with his mother might fall short of stimulation and support. Spending time in the mall lacks structure, socialization, and support.

DIF: Cognitive Level: Application REF: Page 291 TOP: Nursing Process: Planning

MSC: NCLEX: Psychosocial Integrity

25. A patient with catatonic schizophrenia has been standing with his left arm upraised and his right foot off the floor for the majority of the last 20 hours, eating only when allowed to eat standing up. Which nursing intervention has priority for this patient?

a.

Providing high-calorie drinks hourly

b.

Assessing for lower extremity edema bid

c.

Taking the patient to activities therapy once daily

d.

Encouraging the patient to sit or lie down for 30 minutes hourly

ANS: B

Patients who maintain one position for long periods of time should be assessed for dependent edema. In this case, the nurse would look for edema of the lower extremities and would be concerned about the pressure exerted by standing on one foot for long periods of time. Such encouragement would probably be met with resistance by the patient. High-calorie drinks would be necessary if the patient failed to eat at meals. The patient probably would not be able to cognitively process what is required to participate in activities.

DIF: Cognitive Level: Application REF: Page 275

TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

26. Which nursing action best addresses the needs of a paranoid patient who believes the food is poisoned?

a.

Explaining that others eat the food and are not harmed

b.

Allowing the patient to select food from vending machines

c.

Encouraging the patient to discuss why someone would poison the food

d.

Taking steps to prevent the patient from verbalizing the delusional thoughts

ANS: B

Patients who think hospital food is being poisoned will sometimes eat wrapped foods that have not been opened, and occasionally, they may eat food brought from the outside by a trusted person. Delusions are fixed, false beliefs that cannot be refuted by logic. The patient will probably state that the others have been given the antidote to the poison. Encouraging discussion about the delusion is not therapeutic. Although it is wise to minimize the amount of discussion about delusions, refusing to allow the patient to speak about the delusions will not foster a therapeutic alliance.

DIF: Cognitive Level: Application REF: Page 273 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

27. Prior to discharge, the nurse plans to teach the patient and family about relapse. Which items will the nurse include in the teaching?

a.

Recognizing warning signs of relapse

b.

Using street drugs judiciously and only in small amounts

c.

Lowering medication dosage to manage emerging side effects

d.

Notifying the nurse of warning signs present for more than one month

ANS: A

The patient and family must be aware of signs of impending relapse. These signs are usually similar to those that the patient experienced prior to hospitalization and will be patient-specific. The nurse should be notified ASAP, rather than waiting two weeks. Patients should never adjust medication dosage. Street drug use often precipitates relapse since many street drugs are dopaminergic.

DIF: Cognitive Level: Application REF: Page 277

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

28. Because of the cognitive disturbances associated with schizophrenia, which technique will be useful as the nurse teaches a patient about self-management?

a.

Use only verbal instruction.

b.

Teach material in small segments.

c.

Offer opportunities for making numerous choices.

d.

Plan the teaching for a time when the patient has been recently medicated.

ANS: B

Patients with cognitive disturbances should be taught small blocks of information at a time and given frequent reinforcement. Both verbal and visual materials should be used since processing of verbal stimuli may be more impaired. Teaching should be scheduled when the patient is most alert. A large number of choices may be confusing for the person, but a few simple choices may be included.

DIF: Cognitive Level: Application REF: Page 279

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

29. The wife of a patient newly diagnosed with paranoid schizophrenia is concerned that her husband will be this sick for the rest of his life. What information can the nurse provide to the wife?

a.

This disorder generally responds well with treatment and follow-up.

b.

All types of schizophrenia by their nature are chronic relapsing disorders.

c.

Outcomes are related to the patients pre-hospital symptoms of disorganization.

d.

The typical outcome for this diagnosis is that total remission is not achievable.

ANS: A

The prognosis for paranoid schizophrenia is good with appropriate treatment and effective follow-up. The remaining options are not correct when considering this type of schizophrenia

DIF: Cognitive Level: Application REF: Page 274

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

30. A patient is exhibiting auditory hallucinations in addition to being forgetful and easily confused. Which diagnosis does the nurse base this patients interventions on?

a.

Social isolation

b.

Deficient knowledge

c.

Situational low self-esteem

d.

Impaired cognitive functioning

ANS: D

Schizophrenia may alter cognitive functioning, including memory, retention, attention, and the processing of incoming information. Altered cognition accounts for many of the symptoms mentioned in the scenario. Knowing that cognition is altered, the nurse can adjust plans to take the deficits into account. The patient is not exhibiting symptoms that would warrant any of the other options.

DIF: Cognitive Level: Application REF: Page 263 TOP: Nursing Process: Planning

MSC: NCLEX: Psychosocial Integrity

31. A patient experiences intrusive, insulting auditory hallucinations. Which independent behavioral technique can the nurse teach the patient to employ when the voices are troublesome?

a.

Introduce a distraction like reading.

b.

Use positive talk to offset the insults.

c.

Sing or whistle to compete with the voices.

d.

Increase the daily dose of an antipsychotic medication.

ANS: C

This action provides an alternative to listening to the voices and gives the patient a sense of control. The patient should not adjust medication independently. Reading will not be particularly effective, because the voices are uncontested in a quiet atmosphere. Positive talk is generally used to positively affect self-esteem.

DIF: Cognitive Level: Application REF: Page 279

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

32. A patient with schizophrenia tells the nurse as they sit in the day room, I hear voices telling me bad things. The most therapeutic response the nurse can make is:

a.

Tell me what the voices are saying.

b.

I believe you hear voices, but I dont hear them myself.

c.

The voices are not real. Theyre a product of your imagination.

d.

Do you think the voices would go away if we went into your room to talk?

ANS: B

By voicing his or her own reality related to the voices, the nurse does not deny the patients experiences but helps the patient distinguish actual voices from those resulting from internal stimulation. Discussing what the voices are saying serves only to validate the reality of the voices. Challenging the voices will cause the patient to defend his perceptions and thereby reinforce the importance of the hallucination. Asking to move validates the reality of the voices and is not a helpful action since the voices go where the patient goes.

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TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

33. A patient tells the nurse, When Im in the day room, I hear people whispering about me, and that makes me want to punch them. What direction will the nurse provide the staff regarding interacting with this patient?

a.

To minimize the need to whisper, utilize nonverbal techniques when possible.

b.

Stay physically close to this patient and use touch as a tool to interact with him.

c.

Treat this patient matter-of-factly. Be direct; dont talk about him or others in his presence.

d.

Interact with this patient only when necessary. The fewer interactions, the fewer misinterpretations there will be.

ANS: C

This approach is important when providing care for a patient who is misinterpreting reality and is suspicious of the motives of others. Ostracizing the patient is non-therapeutic. Patients often misinterpret touch as threatening. This might promote loss of control. Using nonverbal communication techniques would be nontherapeutic as it would increase patient anxiety and promote loss of control.

DIF: Cognitive Level: Application REF: Page 286

TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

34. A patient with schizophrenia is medication compliant and has well-controlled symptoms. He has, however, never been successful in holding a job because of poor social skills and lack of understanding of basic job skills. The nurse case manager should consider referring the patient:

a.

For cognitive therapy

b.

To assertiveness training

c.

To a day hospital program

d.

For psychosocial rehabilitation

ANS: D

Psychosocial rehabilitation helps patients readjust to community living by promoting development of necessary skills. Social skills training and job skills training programs are usually available. The patient does not need the more intensive services found in a day hospital. Cognitive therapy will not offer the needed community living skills training. Assertiveness training is only a small portion of the community living skills the patient needs.

DIF: Cognitive Level: Application REF: Page 288 TOP: Nursing Process: Planning

MSC: NCLEX: Psychosocial Integrity

35. A patient prescribed an antipsychotic medication develops a high fever, unstable blood pressure, and muscle rigidity. Her next dose of medication is due. The nurse should:

a.

Administer the medication and monitor the vital signs every 4 hours.

b.

Give a lower dose of the medication for 24 hours and monitor the blood pressure.

c.

Prepare to administer a prn dose of the anticholinergic drug benztropine (Cogentin).

d.

Hold the medication and immediately describe the patients symptoms to the doctor.

ANS: D

These symptoms could be related to a possibly fatal disorder called neuroleptic malignant syndrome (NMS), and the nurse should hold the medication and contact the doctor immediately. The other options are inappropriate in light of the seriousness of the situation.

DIF: Cognitive Level: Analysis REF: Page 289

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1. Which interventions will the nurse implement to preserve milieu safety when a patient becomes agitated? Select all that apply.

a.

Project confidence and control.

b.

Provide a show of force when appropriate.

c.

Ask the agitated patient why they are feeling so aggressive.

d.

Move to within 5 feet of the patient to help contain their movement.

e.

Provide the patient with several options as means of de-escalating the crisis.

ANS: A, B, E

The correct options demonstrate that the staff is in control without unnecessarily challenging the patient. Asking why is often interpreted as being challenging and often serves to future agitate the patient. Eight feet is considered to be the therapeutic distance between patient and staff in this type of situation.

DIF: Cognitive Level: Application REF: Page 293 TOP: Nursing Process: Planning

MSC: NCLEX: Psychosocial Integrity

2. Which interventions will the nurse implement to assure effective staff crises management skills? Select all that apply.

a.

Schedule regular staff crises simulations.

b.

Encourage the staff to discuss the details of unit crises.

c.

Attempt to identify staff who are ineffective during crises.

d.

Review documentation that describe the details of unit crises.

e.

Review unit crises management policies for needed updates.

ANS: A, B, D, E

The correct options empower the staff while improving/maintaining their crises management skills. The failures of the process should be identified without blaming staff for ineffective crises management.

DIF: Cognitive Level: Application REF: Page 293 TOP: Nursing Process: Planning

MSC: NCLEX: Psychosocial Integrity

Copyright 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

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