Chapter 16 My Nursing Test Banks

 

Kneisl, Contemporary Psychiatric-Mental Health Nursing, 3/e Test Bank
Chapter 16

Question 1

Type: MCSA

The nurse is interacting with a client. The client states, I am from the planet Shoz, so I am a Shozoid. The client is manifesting which type of communication?

1. Echolalia

2. Neologism

3. Clang association

4. Blocking

Correct Answer: 2

Rationale 1: Neologism refers to words or meanings that may be made up by the client and have special meaning to him. The clients usage of Shoz and Shozoid represent neologisms. Blocking refers to stopping a thought or sentence abruptly without finishing the thought. Clang association refers to the use of words which rhyme or sound alike but may not make sense. Echolalia refers to parroting back what was just said.

Rationale 2: Neologism refers to words or meanings that may be made up by the client and have special meaning to him. The clients usage of Shoz and Shozoid represent neologisms. Blocking refers to stopping a thought or sentence abruptly without finishing the thought. Clang association refers to the use of words which rhyme or sound alike but may not make sense. Echolalia refers to parroting back what was just said.

Rationale 3: Neologism refers to words or meanings that may be made up by the client and have special meaning to him. The clients usage of Shoz and Shozoid represent neologisms. Blocking refers to stopping a thought or sentence abruptly without finishing the thought. Clang association refers to the use of words which rhyme or sound alike but may not make sense. Echolalia refers to parroting back what was just said.

Rationale 4: Neologism refers to words or meanings that may be made up by the client and have special meaning to him. The clients usage of Shoz and Shozoid represent neologisms. Blocking refers to stopping a thought or sentence abruptly without finishing the thought. Clang association refers to the use of words which rhyme or sound alike but may not make sense. Echolalia refers to parroting back what was just said.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Describe the central features of schizophrenia.

Question 2

Type: MCSA

The client tells the nurse, The world will end tonight at midnight. Armageddon is upon us!! Which type of delusion is this?

1. Religious

2. Grandiose

3. Nihilistic

4. Persecutory

Correct Answer: 3

Rationale 1: Nihilistic delusions involve fixed false illogical beliefs about the world ending. Persecutory delusions involve the belief that others intend to harm or kill the client. Grandiose delusions involve beliefs that the client is famous or powerful. Religious delusions involve specific references to religion.

Rationale 2: Nihilistic delusions involve fixed false illogical beliefs about the world ending. Persecutory delusions involve the belief that others intend to harm or kill the client. Grandiose delusions involve beliefs that the client is famous or powerful. Religious delusions involve specific references to religion.

Rationale 3: Nihilistic delusions involve fixed false illogical beliefs about the world ending. Persecutory delusions involve the belief that others intend to harm or kill the client. Grandiose delusions involve beliefs that the client is famous or powerful. Religious delusions involve specific references to religion.

Rationale 4: Nihilistic delusions involve fixed false illogical beliefs about the world ending. Persecutory delusions involve the belief that others intend to harm or kill the client. Grandiose delusions involve beliefs that the client is famous or powerful. Religious delusions involve specific references to religion.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Describe the central features of schizophrenia.

Question 3

Type: MCSA

A client is informed that his family refuses to allow him to return to the familys home because of recent violent behavior. The clients expression remains blank; there is no apparent reaction to this statement. The client then asks what time dinner is served. The client is exhibiting:

1. Inappropriate affect.

2. Blunted affect.

3. Flat affect.

4. Mutism.

Correct Answer: 3

Rationale 1: Flat affect is defined as a total lack of emotion or expression. The client does not appear to display inappropriate or incongruent affect. Blunted affect is defined as having a minimal emotional response to a person or event. Mutism is defined as an inability or refusal to speak when able to do so.

Rationale 2: Flat affect is defined as a total lack of emotion or expression. The client does not appear to display inappropriate or incongruent affect. Blunted affect is defined as having a minimal emotional response to a person or event. Mutism is defined as an inability or refusal to speak when able to do so.

Rationale 3: Flat affect is defined as a total lack of emotion or expression. The client does not appear to display inappropriate or incongruent affect. Blunted affect is defined as having a minimal emotional response to a person or event. Mutism is defined as an inability or refusal to speak when able to do so.

Rationale 4: Flat affect is defined as a total lack of emotion or expression. The client does not appear to display inappropriate or incongruent affect. Blunted affect is defined as having a minimal emotional response to a person or event. Mutism is defined as an inability or refusal to speak when able to do so.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Describe the central features of schizophrenia.

Question 4

Type: MCSA

A client tells the nurse, I refuse to take quetiapine (Seroquel) because it is manufactured by Al Qaeda. If I take it, Ill die. This is an example of:

1. A negative symptom of schizophrenia called alogia.

2. A negative symptom of schizophrenia called avolition.

3. A positive symptom of schizophrenia called delusion.

4. A characteristic of schizophrenia called ambivalence.

Correct Answer: 3

Rationale 1: The clients statement is an example of the positive symptom of schizophrenia called delusion, which is a mistaken or false fixed belief about the self or the environment. The clients statement is not an example of ambivalence which is defined as concurrent conflicting emotions, thoughts, or actions toward a person, object, or concept. It is also not an example of the tendency to use minimal words to speak called alogia, or of a lack of motivation called avolition.

Rationale 2: The clients statement is an example of the positive symptom of schizophrenia called delusion, which is a mistaken or false fixed belief about the self or the environment. The clients statement is not an example of ambivalence which is defined as concurrent conflicting emotions, thoughts, or actions toward a person, object, or concept. It is also not an example of the tendency to use minimal words to speak called alogia, or of a lack of motivation called avolition.

Rationale 3: The clients statement is an example of the positive symptom of schizophrenia called delusion, which is a mistaken or false fixed belief about the self or the environment. The clients statement is not an example of ambivalence which is defined as concurrent conflicting emotions, thoughts, or actions toward a person, object, or concept. It is also not an example of the tendency to use minimal words to speak called alogia, or of a lack of motivation called avolition.

Rationale 4: The clients statement is an example of the positive symptom of schizophrenia called delusion, which is a mistaken or false fixed belief about the self or the environment. The clients statement is not an example of ambivalence which is defined as concurrent conflicting emotions, thoughts, or actions toward a person, object, or concept. It is also not an example of the tendency to use minimal words to speak called alogia, or of a lack of motivation called avolition.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Describe the central features of schizophrenia.

Question 5

Type: MCMA

A client talks in a monotone voice and shows no emotion when speaking. The client tells the nurse, I want to stay in bed all day. I do not enjoy watching television like I used to. I do not want to talk with other people. Which of the following symptoms of schizophrenia are illustrated in this scenario?

Standard Text: Select all that apply.

1. Alogia

2. Flat affect

3. Anhedonia

4. Avolition

5. Apathy

Correct Answer: 2,3,4,5

Rationale 1: Alogia. The client is speaking in full sentences. Alogia is the tendency to use minimal words to speak.

Rationale 2: Flat affect. The client is speaking in a monotone voice and shows no emotion, fitting the definition of flat affect.

Rationale 3: Anhedonia. The client states it is no longer enjoyable to watch television. Anhedonia is defined as the lack of interest in normally pleasurable activities.

Rationale 4: Avolition. The client wants to remain in bed, exhibiting a lack of desire to engage in activities.

Rationale 5: Apathy. The clients statement about not wanting to talk to other people indicates feelings of indifference toward events and people.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Describe the central features of schizophrenia.

Question 6

Type: MCSA

Which of the following statements are accurate descriptions of schizoaffective disorder?

1. The mood component of schizoaffective disorder is depression.

2. Alterations in mood and thought process occur simultaneously in schizoaffective disorder.

3. A client with schizoaffective disorder usually has hallucinations and delusions only when experiencing a manic or depressed state.

4. The prognosis for schizoaffective disorder is substantially worse than for schizophrenia.

Correct Answer: 2

Rationale 1: Alterations in mood and thought process occurring simultaneously accurately describe schizoaffective disorder. The prognosis for schizoaffective disorder is slightly better than for schizophrenia. Schizoaffective disorder is associated with mania and depression. A client with schizoaffective disorder may have hallucinations and delusions at any time despite ones mood.

Rationale 2: Alterations in mood and thought process occurring simultaneously accurately describe schizoaffective disorder. The prognosis for schizoaffective disorder is slightly better than for schizophrenia. Schizoaffective disorder is associated with mania and depression. A client with schizoaffective disorder may have hallucinations and delusions at any time despite ones mood.

Rationale 3: Alterations in mood and thought process occurring simultaneously accurately describe schizoaffective disorder. The prognosis for schizoaffective disorder is slightly better than for schizophrenia. Schizoaffective disorder is associated with mania and depression. A client with schizoaffective disorder may have hallucinations and delusions at any time despite ones mood.

Rationale 4: Alterations in mood and thought process occurring simultaneously accurately describe schizoaffective disorder. The prognosis for schizoaffective disorder is slightly better than for schizophrenia. Schizoaffective disorder is associated with mania and depression. A client with schizoaffective disorder may have hallucinations and delusions at any time despite ones mood.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Distinguish among the subtypes of schizophrenia.

Question 7

Type: MCSA

A client admitted to the inpatient unit has a diagnosis of schizophrenia, residual type. The nursing diagnosis which has the highest priority for this client is:

1. Disturbed Thought Process

2. Impaired Social Interaction

3. Risk for Violence: Self-Directed or Other-Directed

4. Impaired Verbal Communication

Correct Answer: 3

Rationale 1: Risk for Violence: Self-Directed or Other-Directed is most closely related to patient safety, which is the highest priority in nursing care of any client. Impaired Social Interaction, Disturbed Thought Processes, and Verbal Communication are accurate and important nursing diagnoses, but client safety is the highest priority for planning care.

Rationale 2: Risk for Violence: Self-Directed or Other-Directed is most closely related to patient safety, which is the highest priority in nursing care of any client. Impaired Social Interaction, Disturbed Thought Processes, and Verbal Communication are accurate and important nursing diagnoses, but client safety is the highest priority for planning care.

Rationale 3: Risk for Violence: Self-Directed or Other-Directed is most closely related to patient safety, which is the highest priority in nursing care of any client. Impaired Social Interaction, Disturbed Thought Processes, and Verbal Communication are accurate and important nursing diagnoses, but client safety is the highest priority for planning care.

Rationale 4: Risk for Violence: Self-Directed or Other-Directed is most closely related to patient safety, which is the highest priority in nursing care of any client. Impaired Social Interaction, Disturbed Thought Processes, and Verbal Communication are accurate and important nursing diagnoses, but client safety is the highest priority for planning care.

Global Rationale:

Cognitive Level: Creating

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Distinguish among the subtypes of schizophrenia.

Question 8

Type: MCSA

Which of the following behaviors is characteristic of a client with disorganized schizophrenia?

1. A client tells the nurse he is being monitored by the FBI.

2. A client tells the nurse, All is well, but the well is dry, so why bother with clock and tock, mock, lock, jock.

3. A client comes to the nursing station and asks for something to help calm my nerves.

4. A client sits in the corner rocking back and forth crying because the voices are telling me I am a lousy good-for-nothing.

Correct Answer: 2

Rationale 1: A client tells the nurse he is being monitored by the FBI. This client is verbalizing paranoid thoughts.

Rationale 2: A client tells the nurse all is well, but the well is dry, so why bother with clock and tock, mock, lock, jock. This client is manifesting looseness of association and clanging, which is manifestation of disorganized thoughts and speech.

Rationale 3: A client who has been pacing in the hallway, comes to the nursing station and asks for something to help calm my nerves. This is an appropriate request.

Rationale 4: A client sits in the corner rocking back and forth crying because the voices are telling me I am a lousy good-for-nothing. This client is verbalizing auditory hallucinations, which are a positive symptom of schizophrenia.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Distinguish among the subtypes of schizophrenia.

Question 9

Type: MCSA

A client who is diagnosed with schizophrenia, paranoid type, tells the nurse, I will take these antipsychotic medications to help alleviate the voices. I will not take these antipsychotic medications because of the weight gain. This client is exhibiting:

1. Body image disturbance.

2. Decisional conflict.

3. Magical thinking.

4. Noncompliance.

Correct Answer: 2

Rationale 1: Decisional conflict, which may be due to biochemical changes in the brain, is correct. The client is having difficulty deciding whether or not to take antipsychotic medication. The client is not exhibiting noncompliance, or refusal to adhere to the treatment regimen. However, noncompliance may occur as a result of ambivalence and decisional conflict. The client is not exhibiting body image disturbance though this is common in people with schizophrenia in which clients may lose the sense of where their bodies leave off and where inanimate objects begin. The client is not expressing magical thinking, which is characterized by the idea that events can occur because someone wishes them to occur.

Rationale 2: Decisional conflict, which may be due to biochemical changes in the brain, is correct. The client is having difficulty deciding whether or not to take antipsychotic medication. The client is not exhibiting noncompliance, or refusal to adhere to the treatment regimen. However, noncompliance may occur as a result of ambivalence and decisional conflict. The client is not exhibiting body image disturbance though this is common in people with schizophrenia in which clients may lose the sense of where their bodies leave off and where inanimate objects begin. The client is not expressing magical thinking, which is characterized by the idea that events can occur because someone wishes them to occur.

Rationale 3: Decisional conflict, which may be due to biochemical changes in the brain, is correct. The client is having difficulty deciding whether or not to take antipsychotic medication. The client is not exhibiting noncompliance, or refusal to adhere to the treatment regimen. However, noncompliance may occur as a result of ambivalence and decisional conflict. The client is not exhibiting body image disturbance though this is common in people with schizophrenia in which clients may lose the sense of where their bodies leave off and where inanimate objects begin. The client is not expressing magical thinking, which is characterized by the idea that events can occur because someone wishes them to occur.

Rationale 4: Decisional conflict, which may be due to biochemical changes in the brain, is correct. The client is having difficulty deciding whether or not to take antipsychotic medication. The client is not exhibiting noncompliance, or refusal to adhere to the treatment regimen. However, noncompliance may occur as a result of ambivalence and decisional conflict. The client is not exhibiting body image disturbance though this is common in people with schizophrenia in which clients may lose the sense of where their bodies leave off and where inanimate objects begin. The client is not expressing magical thinking, which is characterized by the idea that events can occur because someone wishes them to occur.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Distinguish among the subtypes of schizophrenia.

Question 10

Type: MCSA

Which of the following statements would not be accurate regarding the dopamine hypothesis?

1. Typical antipsychotic medications cause fewer extrapyramidal side effects than traditional antipsychotic medications.

2. Atypical antipsychotic medications block serotonin and dopamine.

3. Numerous types of dopamine receptors have been found to exist in varied regions of the brain.

4. Positive symptoms of schizophrenia respond more readily to traditional antipsychotic medications than the newer atypical medications.

Correct Answer: 4

Rationale 1: Negative symptoms of schizophrenia, rather than positive symptoms, respond more readily to traditional antipsychotic medications than the newer atypical medications. It is true that typical antipsychotic medications block serotonin and dopamine, numerous types of dopamine receptors have been found to exist in varied regions of the brain, and atypical antipsychotic medications cause fewer extrapyramidal side effects than traditional antipsychotic medications.

Rationale 2: Negative symptoms of schizophrenia, rather than positive symptoms, respond more readily to traditional antipsychotic medications than the newer atypical medications. It is true that typical antipsychotic medications block serotonin and dopamine, numerous types of dopamine receptors have been found to exist in varied regions of the brain, and atypical antipsychotic medications cause fewer extrapyramidal side effects than traditional antipsychotic medications.

Rationale 3: Negative symptoms of schizophrenia, rather than positive symptoms, respond more readily to traditional antipsychotic medications than the newer atypical medications. It is true that typical antipsychotic medications block serotonin and dopamine, numerous types of dopamine receptors have been found to exist in varied regions of the brain, and atypical antipsychotic medications cause fewer extrapyramidal side effects than traditional antipsychotic medications.

Rationale 4: Negative symptoms of schizophrenia, rather than positive symptoms, respond more readily to traditional antipsychotic medications than the newer atypical medications. It is true that typical antipsychotic medications block serotonin and dopamine, numerous types of dopamine receptors have been found to exist in varied regions of the brain, and atypical antipsychotic medications cause fewer extrapyramidal side effects than traditional antipsychotic medications.

Global Rationale:

Cognitive Level: Evaluating

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Compare and contrast the various biopsychosocial theories that address the possible causes of schizophrenia.

Question 11

Type: MCSA

A statement which accurately describe genetics and schizophrenia would be:

1. One single gene is responsible for producing schizophrenia.

2. There is strong evidence that environmental factors do not affect the risk of developing schizophrenia.

3. 10% of first degree relatives (children, siblings, parents) are diagnosed with schizophrenia at some point in their lives.

4. The chance of monozygotic (identical) twins both having schizophrenia is 100%.

Correct Answer: 3

Rationale 1: 10% of first degree relatives (children, siblings, parents) are diagnosed with schizophrenia at some point in their lives. One single gene is not responsible for producing schizophrenia. There is strong evidence that environmental factors do affect the risk of developing schizophrenia. The chance of monozygotic (identical) twins both having schizophrenia is 25 to 39%, not 100%.

Rationale 2: 10% of first degree relatives (children, siblings, parents) are diagnosed with schizophrenia at some point in their lives. One single gene is not responsible for producing schizophrenia. There is strong evidence that environmental factors do affect the risk of developing schizophrenia. The chance of monozygotic (identical) twins both having schizophrenia is 25 to 39%, not 100%.

Rationale 3: 10% of first degree relatives (children, siblings, parents) are diagnosed with schizophrenia at some point in their lives. One single gene is not responsible for producing schizophrenia. There is strong evidence that environmental factors do affect the risk of developing schizophrenia. The chance of monozygotic (identical) twins both having schizophrenia is 25 to 39%, not 100%.

Rationale 4: 10% of first degree relatives (children, siblings, parents) are diagnosed with schizophrenia at some point in their lives. One single gene is not responsible for producing schizophrenia. There is strong evidence that environmental factors do affect the risk of developing schizophrenia. The chance of monozygotic (identical) twins both having schizophrenia is 25 to 39%, not 100%.

Global Rationale:

Cognitive Level: Evaluating

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Compare and contrast the various biopsychosocial theories that address the possible causes of schizophrenia.

Question 12

Type: MCSA

It would be inaccurate to state that the brain structure in people with schizophrenia:

1. Shows changes in the frontotemporal cortical gray matter.

2. Shows changes in the hippocampal area.

3. Shows changes in the parietal area.

4. Is different from those without schizophrenia.

Correct Answer: 3

Rationale 1: The brains of people with schizophrenia do not show changes in the parietal area. The brains of people with schizophrenia do have different structures from those without schizophrenia. They show changes in the hippocampal area of the brain and in the frontotemporal cortical gray matter.

Rationale 2: The brains of people with schizophrenia do not show changes in the parietal area. The brains of people with schizophrenia do have different structures from those without schizophrenia. They show changes in the hippocampal area of the brain and in the frontotemporal cortical gray matter.

Rationale 3: The brains of people with schizophrenia do not show changes in the parietal area. The brains of people with schizophrenia do have different structures from those without schizophrenia. They show changes in the hippocampal area of the brain and in the frontotemporal cortical gray matter.

Rationale 4: The brains of people with schizophrenia do not show changes in the parietal area. The brains of people with schizophrenia do have different structures from those without schizophrenia. They show changes in the hippocampal area of the brain and in the frontotemporal cortical gray matter.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Compare and contrast the various biopsychosocial theories that address the possible causes of schizophrenia.

Question 13

Type: MCMA

Select the responses which are true regarding the interactional model for schizophrenia.

Standard Text: Select all that apply.

1. People with schizophrenia have a greater potential for vulnerability to stress.

2. People with schizophrenia have a greater likelihood of relapsing if they are from families demonstrating high expressed emotion (EE).

3. People with schizophrenia are less sensitive to interpersonal stressors.

4. Vulnerability, stressors, and risk factors enhance and potentiate each other in people with schizophrenia.

5. People with schizophrenia are less responsive to environmental stressors.

Correct Answer: 1,2,4

Rationale 1: People with schizophrenia have a greater potential for vulnerability to stress. The stressors a client with schizophrenia experiences can overwhelm the resources available and symptoms result.

Rationale 2: People with schizophrenia have a greater likelihood of relapsing if they are from families demonstrating high expressed emotion (EE). The familys emotional tone can influence the course of schizophrenia over time.

Rationale 3: People with schizophrenia are less sensitive to environmental stressors. People with schizophrenia are more sensitive to environmental stressors.

Rationale 4: Vulnerability, stressors, and risk factors enhance and potentiate each other in people with schizophrenia. When these factors interact with each other the person with schizophrenia is at greater risk for decompensating according to the interactive model.

Rationale 5: People with schizophrenia are less responsive to interpersonal stressors. People with schizophrenia are more sensitive to interpersonal stressors.

Global Rationale:

Cognitive Level: Evaluating

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Explain how psychological and social pressures can influence the course of schizophrenia.

Question 14

Type: MCSA

Which of the following statements that address the typical age of onset for schizophrenia is true?

1. The typical age of onset for schizophrenia is early adolescence in both males and females.

2. The typical age of onset for late-onset schizophrenia is age 60.

3. The typical age of onset for schizophrenia is late adolescence to mid-thirties.

4. The typical age of onset for schizophrenia is late thirties to early forties.

Correct Answer: 3

Rationale 1: Late adolescence to mid-thirties is the typical age range for the onset of schizophrenia. The onset of schizophrenia does not usually occur during early adolescence. Most people with schizophrenia do not experience onset in the late thirties to early forties. Rarely does schizophrenia first appear at age 60.

Rationale 2: Late adolescence to mid-thirties is the typical age range for the onset of schizophrenia. The onset of schizophrenia does not usually occur during early adolescence. Most people with schizophrenia do not experience onset in the late thirties to early forties. Rarely does schizophrenia first appear at age 60.

Rationale 3: Late adolescence to mid-thirties is the typical age range for the onset of schizophrenia. The onset of schizophrenia does not usually occur during early adolescence. Most people with schizophrenia do not experience onset in the late thirties to early forties. Rarely does schizophrenia first appear at age 60.

Rationale 4: Late adolescence to mid-thirties is the typical age range for the onset of schizophrenia. The onset of schizophrenia does not usually occur during early adolescence. Most people with schizophrenia do not experience onset in the late thirties to early forties. Rarely does schizophrenia first appear at age 60.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Explain how psychological and social pressures can influence the course of schizophrenia.

Question 15

Type: MCSA

Which of the following interventions provides the most support to assist a client with schizophrenia in adapting to a new social environment?

1. Accompany the client

2. Encourage the client to make new friends

3. Instruct the client in coping strategies

4. Increase physical activity

Correct Answer: 1

Rationale 1: Accompanying the client will provide a source of support during the transition and enable the nurse to assess the clients needs. Encouraging the client to make new friends is not an intervention to provide support. Encouraging the client to increase physical activity is not an intervention to provide support. Providing instruction on coping strategies does not provide direct support to the client.

Rationale 2: Accompanying the client will provide a source of support during the transition and enable the nurse to assess the clients needs. Encouraging the client to make new friends is not an intervention to provide support. Encouraging the client to increase physical activity is not an intervention to provide support. Providing instruction on coping strategies does not provide direct support to the client.

Rationale 3: Accompanying the client will provide a source of support during the transition and enable the nurse to assess the clients needs. Encouraging the client to make new friends is not an intervention to provide support. Encouraging the client to increase physical activity is not an intervention to provide support. Providing instruction on coping strategies does not provide direct support to the client.

Rationale 4: Accompanying the client will provide a source of support during the transition and enable the nurse to assess the clients needs. Encouraging the client to make new friends is not an intervention to provide support. Encouraging the client to increase physical activity is not an intervention to provide support. Providing instruction on coping strategies does not provide direct support to the client.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Explain how psychological and social pressures can influence the course of schizophrenia.

Question 16

Type: MCSA

A client is pacing in the hall. The nurse overhears the client say, Leave me alone. I am not in the Mafia. The best response from the nurse would be:

1. Remember you are safe from the Mafia here in the hospital.

2. Tell me what you are hearing right now.

3. You need to attend the next recreation group. That will help you ignore the voices.

4. You are hearing voices again, right?

Correct Answer: 2

Rationale 1: Tell me what you are hearing right now is an open statement that allows the client to inform the nurse what is being experienced. The nurse does not presume to know what the client is experiencing. You are hearing voices again, right? presumes to know what the client is experiencing without asking the patient directly. You need to attend the next recreation group. That will help you ignore the voices does not ask for an explanation of the clients experiences and implies that a client can ignore voices. Remember you are safe from the Mafia here in the hospital does not ask for an explanation of the clients experiences, so may not be addressing the clients needs at this time. This is an example of false reassurance.

Rationale 2: Tell me what you are hearing right now is an open statement that allows the client to inform the nurse what is being experienced. The nurse does not presume to know what the client is experiencing. You are hearing voices again, right? presumes to know what the client is experiencing without asking the patient directly. You need to attend the next recreation group. That will help you ignore the voices does not ask for an explanation of the clients experiences and implies that a client can ignore voices. Remember you are safe from the Mafia here in the hospital does not ask for an explanation of the clients experiences, so may not be addressing the clients needs at this time. This is an example of false reassurance.

Rationale 3: Tell me what you are hearing right now is an open statement that allows the client to inform the nurse what is being experienced. The nurse does not presume to know what the client is experiencing. You are hearing voices again, right? presumes to know what the client is experiencing without asking the patient directly. You need to attend the next recreation group. That will help you ignore the voices does not ask for an explanation of the clients experiences and implies that a client can ignore voices. Remember you are safe from the Mafia here in the hospital does not ask for an explanation of the clients experiences, so may not be addressing the clients needs at this time. This is an example of false reassurance.

Rationale 4: Tell me what you are hearing right now is an open statement that allows the client to inform the nurse what is being experienced. The nurse does not presume to know what the client is experiencing. You are hearing voices again, right? presumes to know what the client is experiencing without asking the patient directly. You need to attend the next recreation group. That will help you ignore the voices does not ask for an explanation of the clients experiences and implies that a client can ignore voices. Remember you are safe from the Mafia here in the hospital does not ask for an explanation of the clients experiences, so may not be addressing the clients needs at this time. This is an example of false reassurance.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Implement the major nursing implications in caring for clients with difficult and chronic illnesses such as schizophrenia.

Question 17

Type: MCMA

A client is experiencing delusions and appears to be frightened. Which of the following actions are appropriate nursing interventions?

Standard Text: Select all that apply.

1. Validate the clients feelings in response to altered perceptions.

2. Inform the client that their delusions and hallucinations are just bad dreams.

3. Assure the client that the nurse does not experience delusions or hallucinations.

4. Provide reality testing.

5. Keep the client physically safe.

Correct Answer: 1,4,5

Rationale 1: Validate the clients feelings in response to altered perceptions. It is appropriate to validate the clients feelings in response to altered perceptions.

Rationale 2: Inform the client that their delusions and hallucinations are just bad dreams. It is not appropriate to inform the client that their delusions and hallucinations are just bad dreams.

Rationale 3: Assure the client that the nurse does not experience delusions or hallucinations. It is not appropriate to assure the client that the nurse does not experience delusions or hallucinations.

Rationale 4: Provide reality testing. Providing reality testing is an appropriate nursing measure.

Rationale 5: Keep the client physically safe. Keeping the client safe is an appropriate nursing measure.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Implement the major nursing implications in caring for clients with difficult and chronic illnesses such as schizophrenia.

Question 18

Type: MCSA

A nurse is leading an inpatient group for clients with schizophrenia. Which statements address the two main categories of nursing activities?

1. We will listen to each others best and worst experiences of the last week.

2. We will go around the room and each person will state a personal goal for today.

3. If you can increase your self-assessment skills, youll be able to tell when youre getting more stressed.

4. Were going to discuss current events.

5. Group members can help each other identify and improve their coping skills so that each has a better tool chest to draw from when experiencing stress.

Correct Answer: 3

Rationale 1: We will listen to each others best and worst experiences of the last week. This activity alone is not directed toward developing coping strategies or self-monitoring. Further work is needed to learn how the client responded and what coping skills the client might have applied.

Rationale 2: We will go around the room and each person will state a personal goal for today. This activity is not directed toward developing coping strategies or self-monitoring. In addition, it may increase anxiety in each client by insisting on active participation.

Rationale 3: If you can increase your self-assessment skills, youll be able to tell when youre getting more stressed. This statement relates to self-monitoring for symptoms.

Rationale 4: Were going to discuss current events. This is an intervention that will assist with reality testing but does not relate to developing coping strategies or self-monitoring.

Rationale 5: Group members can help each other identify and improve their coping skills so that each has a better tool chest to draw from when experiencing stress. This statement relates to developing coping strategies to maintain stabilization.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Implement the major nursing implications in caring for clients with difficult and chronic illnesses such as schizophrenia.

Question 19

Type: MCSA

A client admitted to the inpatient unit has a diagnosis of schizophrenia, residual type. The nursing diagnosis that has the highest priority for this client is:

1. Disturbed Thought Process

2. Impaired Social Interaction

3. Impaired Verbal Communication

4. Risk for Violence: Self-Directed or Other-Directed

Correct Answer: 4

Rationale 1: Risk for Violence: Self-Directed or Other-Directed is the nursing diagnosis that is most closely related to patient safety, which is the highest priority in nursing care of any client. Impaired Social Interaction, Disturbed Thought Processes, and Impaired Verbal Communication represent accurate and important nursing diagnoses, but client safety is the highest priority for planning care.

Rationale 2: Risk for Violence: Self-Directed or Other-Directed is the nursing diagnosis that is most closely related to patient safety, which is the highest priority in nursing care of any client. Impaired Social Interaction, Disturbed Thought Processes, and Impaired Verbal Communication represent accurate and important nursing diagnoses, but client safety is the highest priority for planning care.

Rationale 3: Risk for Violence: Self-Directed or Other-Directed is the nursing diagnosis that is most closely related to patient safety, which is the highest priority in nursing care of any client. Impaired Social Interaction, Disturbed Thought Processes, and Impaired Verbal Communication represent accurate and important nursing diagnoses, but client safety is the highest priority for planning care.

Rationale 4: Risk for Violence: Self-Directed or Other-Directed is the nursing diagnosis that is most closely related to patient safety, which is the highest priority in nursing care of any client. Impaired Social Interaction, Disturbed Thought Processes, and Impaired Verbal Communication represent accurate and important nursing diagnoses, but client safety is the highest priority for planning care.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Implement the major nursing implications in caring for clients with difficult and chronic illnesses such as schizophrenia.

Question 20

Type: MCMA

Which of the following aspects of family communication patterns may be problematic?

Standard Text: Select all that apply.

1. Family members appear to respect individual boundaries.

2. Family members appear to be enmeshed or over-involved with each other.

3. Family members appear to be able to focus and discuss specific topics reasonably with each other.

4. Family members allow each other to finish a sentence without interruption.

5. Family members appear to use language patterns that are unusual in that they are characteristic of the clients family only.

Correct Answer: 2,5

Rationale 1: Family members appear to understand and respect individual boundaries. Problems in family communication patterns are less likely to exist if family members appear to understand and respect individual boundaries.

Rationale 2: Family members appear to be enmeshed or over-involved with each other. Problems in family communication patterns are likely to exist if family members appear to be enmeshed or over-involved with each other.

Rationale 3: Family members appear to be able to focus and discuss specific topics reasonably with each other. Family communication problems are less likely to exist if family members appear to be able to focus and discuss specific topics reasonably with each other.

Rationale 4: Family members allow each other to finish a sentence without interruption. Problems in family communication patterns are less likely to exist if family members show respect by allowing each other to complete a thought without interruption.

Rationale 5: Family members appear to use language patterns that are unusual in that they are characteristic of the clients family only. It is likely to be problematic if family members use language patterns that are unusual to those not in the family.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Partner with and provide support to the families of persons with schizophrenia.

Question 21

Type: MCSA

The sister of a client with schizophrenia asks the nurse what to do when her brother acts like he is talking to someone, but no one is there. Which of the following responses by the nurse would help the sister gain insight into her brothers experience?

1. Tell your brother to go to his room to decrease the amount of stimuli he is experiencing.

2. Tell your brother there is no one else in the room.

3. Give your brother medication for increased anxiety.

4. Ask your brother to describe what he is seeing and hearing.

Correct Answer: 4

Rationale 1: Asking your brother to describe what he is seeing and hearing serves to not only ask the client for information, but also helps validate the clients experiences. The other statements fail to ask the client what is being experienced. Telling your brother there is no one else in the room is phrased incorrectly. A better response would be for the sister to state, I do not see anyone else in the room. Tell me what you see and hear. Telling your brother to go to his room to decrease the amount of stimuli he is experiencing does not address what the client is experiencing. There is no indication the client is experiencing increased anxiety. Additionally, giving medication would not help the sister gain insight into her brothers experience.

Rationale 2: Asking your brother to describe what he is seeing and hearing serves to not only ask the client for information, but also helps validate the clients experiences. The other statements fail to ask the client what is being experienced. Telling your brother there is no one else in the room is phrased incorrectly. A better response would be for the sister to state, I do not see anyone else in the room. Tell me what you see and hear. Telling your brother to go to his room to decrease the amount of stimuli he is experiencing does not address what the client is experiencing. There is no indication the client is experiencing increased anxiety. Additionally, giving medication would not help the sister gain insight into her brothers experience.

Rationale 3: Asking your brother to describe what he is seeing and hearing serves to not only ask the client for information, but also helps validate the clients experiences. The other statements fail to ask the client what is being experienced. Telling your brother there is no one else in the room is phrased incorrectly. A better response would be for the sister to state, I do not see anyone else in the room. Tell me what you see and hear. Telling your brother to go to his room to decrease the amount of stimuli he is experiencing does not address what the client is experiencing. There is no indication the client is experiencing increased anxiety. Additionally, giving medication would not help the sister gain insight into her brothers experience.

Rationale 4: Asking your brother to describe what he is seeing and hearing serves to not only ask the client for information, but also helps validate the clients experiences. The other statements fail to ask the client what is being experienced. Telling your brother there is no one else in the room is phrased incorrectly. A better response would be for the sister to state, I do not see anyone else in the room. Tell me what you see and hear. Telling your brother to go to his room to decrease the amount of stimuli he is experiencing does not address what the client is experiencing. There is no indication the client is experiencing increased anxiety. Additionally, giving medication would not help the sister gain insight into her brothers experience.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Partner with and provide support to the families of persons with schizophrenia.

Question 22

Type: MCMA

The nurse is providing discharge teaching and anticipatory guidance to the family of a client with schizophrenia who experiences delusions and is easily frightened. Which of the following actions are appropriate nursing interventions?

Standard Text: Select all that apply.

1. Provide reality orientation.

2. Assure the client that the nurse does not experience delusions or hallucinations.

3. Validate the clients feelings in response to altered perceptions.

4. Inform the client that their delusions and hallucinations are just bad dreams.

5. Keep the client physically safe.

Correct Answer: 1,3,5

Rationale 1: Provide reality orientation. The purpose for this is to assist in helping the client distinguish between what is real and what is imagined.

Rationale 2: Assure the client that the nurse does not experience delusions or hallucinations. It is not appropriate to assure the client that the nurse does not experience delusions or hallucinations.

Rationale 3: Validate the clients feelings in response to altered perceptions. It is appropriate to validate the clients feelings in response to altered perceptions.

Rationale 4: Inform the client that their delusions and hallucinations are just bad dreams. It is not appropriate to inform the client that their delusions and hallucinations are just bad dreams.

Rationale 5: Keep the client physically safe. This is an appropriate nursing measure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Partner with and provide support to the families of persons with schizophrenia.

Question 23

Type: MCMA

The nurse developing a family-centered discharge plan of care for a client with schizophrenia would include which of the following?

Standard Text: Select all that apply.

1. Impaired social isolation

2. Activity intolerance

3. Knowledge deficit

4. Potential for caregiver role strain

5. Potential for self-care deficit

Correct Answer:

Rationale 1: Individuals and families caring for family members with a chronic disease like schizophrenia are at risk for a variety of physical and emotional problems related to caregiver role strain. At this point in time there is no data to support the family is experiencing social isolation. The diagnosis of self-care deficit relates specifically to the client and not part of a comprehensive family-centered plan of care. There is no data to support an active diagnosis of activity intolerance or knowledge deficit.

Rationale 2: Individuals and families caring for family members with a chronic disease like schizophrenia are at risk for a variety of physical and emotional problems related to caregiver role strain. At this point in time there is no data to support the family is experiencing social isolation. The diagnosis of self-care deficit relates specifically to the client and not part of a comprehensive family-centered plan of care. There is no data to support an active diagnosis of activity intolerance or knowledge deficit.

Rationale 3: Individuals and families caring for family members with a chronic disease like schizophrenia are at risk for a variety of physical and emotional problems related to caregiver role strain. At this point in time there is no data to support the family is experiencing social isolation. The diagnosis of self-care deficit relates specifically to the client and not part of a comprehensive family-centered plan of care. There is no data to support an active diagnosis of activity intolerance or knowledge deficit.

Rationale 4: Individuals and families caring for family members with a chronic disease like schizophrenia are at risk for a variety of physical and emotional problems related to caregiver role strain. At this point in time there is no data to support the family is experiencing social isolation. The diagnosis of self-care deficit relates specifically to the client and not part of a comprehensive family-centered plan of care. There is no data to support an active diagnosis of activity intolerance or knowledge deficit.

Rationale 5: Individuals and families caring for family members with a chronic disease like schizophrenia are at risk for a variety of physical and emotional problems related to caregiver role strain. At this point in time there is no data to support the family is experiencing social isolation. The diagnosis of self-care deficit relates specifically to the client and not part of a comprehensive family-centered plan of care. There is no data to support an active diagnosis of activity intolerance or knowledge deficit.

Global Rationale:

Cognitive Level: Evaluating

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Partner with and provide support to the families of persons with schizophrenia.

Question 24

Type: MCSA

The nurse is talking with a client diagnosed with schizophrenia about the importance of careful adherence to the medication regimen. Which of the following client reasons is not commonly associated with noncompliance?

1. Lack of access to pharmacies due to financial or transportation concerns

2. Increased ability to trust healthcare providers who prescribe medications

3. Inability to understand instructions for taking medications

4. Side effects causing extreme discomfort

Correct Answer: 2

Rationale 1: Clients with schizophrenia usually have a decreased, not increased, ability to trust healthcare providers who prescribe medications. A client may refuse to adhere to the medication regimen because side effects are causing extreme discomfort. Clients with schizophrenia may have difficulty obtaining medication because of a lack of access to pharmacies due to financial or transportation concerns. Compliance problems may also occur if the client does not understand how to take the medication.

Rationale 2: Clients with schizophrenia usually have a decreased, not increased, ability to trust healthcare providers who prescribe medications. A client may refuse to adhere to the medication regimen because side effects are causing extreme discomfort. Clients with schizophrenia may have difficulty obtaining medication because of a lack of access to pharmacies due to financial or transportation concerns. Compliance problems may also occur if the client does not understand how to take the medication.

Rationale 3: Clients with schizophrenia usually have a decreased, not increased, ability to trust healthcare providers who prescribe medications. A client may refuse to adhere to the medication regimen because side effects are causing extreme discomfort. Clients with schizophrenia may have difficulty obtaining medication because of a lack of access to pharmacies due to financial or transportation concerns. Compliance problems may also occur if the client does not understand how to take the medication.

Rationale 4: Clients with schizophrenia usually have a decreased, not increased, ability to trust healthcare providers who prescribe medications. A client may refuse to adhere to the medication regimen because side effects are causing extreme discomfort. Clients with schizophrenia may have difficulty obtaining medication because of a lack of access to pharmacies due to financial or transportation concerns. Compliance problems may also occur if the client does not understand how to take the medication.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Incorporate methods to prevent or minimize relapses in schizophrenia.

Question 25

Type: MCSA

Which of the following psychosocial approaches for treating schizophrenia have been found to have lower relapse rates?

1. Learning is often affected negatively in schizophrenia, so there is not a need to educate clients about schizophrenia and relapse.

2. Setting high goals for clients serves as an incentive for clients to avoid relapse.

3. Weekly individual monitoring can help to identify and intervene with clients who are at risk for relapse.

4. Antipsychotic medications are effective in lowering relapse rates for all clients.

Correct Answer: 3

Rationale 1: Weekly individual monitoring can help to identify and intervene with clients who are at risk for relapse. Antipsychotic medications are effective in lowering relapse rates, but 30 to 40% of all clients relapse within a year after discharge. Although learning is often affected negatively in schizophrenia, there is still a need to educate clients about schizophrenia and relapse. Setting reasonable, achievable goals for clients serves as an incentive for clients to avoid relapse.

Rationale 2: Weekly individual monitoring can help to identify and intervene with clients who are at risk for relapse. Antipsychotic medications are effective in lowering relapse rates, but 30 to 40% of all clients relapse within a year after discharge. Although learning is often affected negatively in schizophrenia, there is still a need to educate clients about schizophrenia and relapse. Setting reasonable, achievable goals for clients serves as an incentive for clients to avoid relapse.

Rationale 3: Weekly individual monitoring can help to identify and intervene with clients who are at risk for relapse. Antipsychotic medications are effective in lowering relapse rates, but 30 to 40% of all clients relapse within a year after discharge. Although learning is often affected negatively in schizophrenia, there is still a need to educate clients about schizophrenia and relapse. Setting reasonable, achievable goals for clients serves as an incentive for clients to avoid relapse.

Rationale 4: Weekly individual monitoring can help to identify and intervene with clients who are at risk for relapse. Antipsychotic medications are effective in lowering relapse rates, but 30 to 40% of all clients relapse within a year after discharge. Although learning is often affected negatively in schizophrenia, there is still a need to educate clients about schizophrenia and relapse. Setting reasonable, achievable goals for clients serves as an incentive for clients to avoid relapse.

Global Rationale:

Cognitive Level: Evaluating

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Incorporate methods to prevent or minimize relapses in schizophrenia.

Question 26

Type: MCMA

Lower relapse rates in schizophrenia have been found to be effective with which of the following treatment approaches?

Standard Text: Select all that apply.

1. Psychosocial treatment only

2. Recognizing schizophrenia as an acute illness

3. Antipsychotic medication exclusively

4. Early intervention

5. The combined use of antipsychotic medication and psychosocial treatment

Correct Answer: 4,5

Rationale 1: Psychosocial treatment only. Lower relapse rates in schizophrenia are not associated with psychosocial treatment only.

Rationale 2: Recognizing schizophrenia as an acute illness. Schizophrenia is a chronic illness. The client with schizophrenia will require ongoing treatment to minimize the potential for relapse.

Rationale 3: Antipsychotic medication exclusively. Before psychosocial treatment was added, there was improvement with antipsychotic medication but less so than with the combination of both.

Rationale 4: Early intervention. Lower relapse rates in schizophrenia are associated with early intervention.

Rationale 5: The combined use of antipsychotic medication and psychosocial treatment. Lower relapse rates in schizophrenia are associated with the combined use of antipsychotic medication and psychosocial treatment.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Incorporate methods to prevent or minimize relapses in schizophrenia.

Question 27

Type: MCSA

Which of the following interventions will increase the clients likelihood of complying with taking psychotropic medications?

1. Give family members information about the clients medication.

2. Encourage the client to take all medication at the same time.

3. Give the client a pamphlet explaining the positive effects of psychotropic medication.

4. Encourage the client to use measures to manage side effects.

Correct Answer: 4

Rationale 1: Encouraging the client to use measures to manage side effects increases the potential for the client to cope with side effects, therefore, increasing compliance. The nurse should help the client develop a schedule for taking medication which will provide the most therapeutic response. Not all medication should be taken at the same time. The nurse should provide instruction and information about the clients medication to a family member or caretaker, validation of the clients understanding is needed to facilitate compliance. Providing the client with a pamphlet does not ensure the client understands the information provided. Validation of understanding is needed to facilitate compliance.

Rationale 2: Encouraging the client to use measures to manage side effects increases the potential for the client to cope with side effects, therefore, increasing compliance. The nurse should help the client develop a schedule for taking medication which will provide the most therapeutic response. Not all medication should be taken at the same time. The nurse should provide instruction and information about the clients medication to a family member or caretaker, validation of the clients understanding is needed to facilitate compliance. Providing the client with a pamphlet does not ensure the client understands the information provided. Validation of understanding is needed to facilitate compliance.

Rationale 3: Encouraging the client to use measures to manage side effects increases the potential for the client to cope with side effects, therefore, increasing compliance. The nurse should help the client develop a schedule for taking medication which will provide the most therapeutic response. Not all medication should be taken at the same time. The nurse should provide instruction and information about the clients medication to a family member or caretaker, validation of the clients understanding is needed to facilitate compliance. Providing the client with a pamphlet does not ensure the client understands the information provided. Validation of understanding is needed to facilitate compliance.

Rationale 4: Encouraging the client to use measures to manage side effects increases the potential for the client to cope with side effects, therefore, increasing compliance. The nurse should help the client develop a schedule for taking medication which will provide the most therapeutic response. Not all medication should be taken at the same time. The nurse should provide instruction and information about the clients medication to a family member or caretaker, validation of the clients understanding is needed to facilitate compliance. Providing the client with a pamphlet does not ensure the client understands the information provided. Validation of understanding is needed to facilitate compliance.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Incorporate methods to prevent or minimize relapses in schizophrenia.

Question 28

Type: MCSA

The nurse manager of the inpatient psychiatric unit is talking with the staff about the interventions to promote independent actions of clients on the chronic schizophrenia unit. Which of the following responses made by the staff indicates lack of insight into the clients illness?

1. I want to learn more about the side effects of the medication.

2. I know when clients hear voices they are not real.

3. I understand that some clients are not able to put on their clothes.

4. I believe clients sometimes need to be isolated help them feel safe.

Correct Answer: 2

Rationale 1: A hallucination is a real experience to the individual To maintain a therapeutic relationship, the nurse should convey acceptance of the clients experience. Acknowledging disbelief of the auditory hallucination may affect the nurses ability to engage in a therapeutic nurseclient relationship. Clients who are low functioning may benefit from assistance with their activities of daily living, such as assisting with dressing. A client who is at risk for harming self or others may need to be isolated to help him or her feel safe by minimizing access to potentially harmful objects. Nurses need to be informed of potential side effects of medications in order to monitor for side effects and instructing others.

Rationale 2: A hallucination is a real experience to the individual To maintain a therapeutic relationship, the nurse should convey acceptance of the clients experience. Acknowledging disbelief of the auditory hallucination may affect the nurses ability to engage in a therapeutic nurseclient relationship. Clients who are low functioning may benefit from assistance with their activities of daily living, such as assisting with dressing. A client who is at risk for harming self or others may need to be isolated to help him or her feel safe by minimizing access to potentially harmful objects. Nurses need to be informed of potential side effects of medications in order to monitor for side effects and instructing others.

Rationale 3: A hallucination is a real experience to the individual To maintain a therapeutic relationship, the nurse should convey acceptance of the clients experience. Acknowledging disbelief of the auditory hallucination may affect the nurses ability to engage in a therapeutic nurseclient relationship. Clients who are low functioning may benefit from assistance with their activities of daily living, such as assisting with dressing. A client who is at risk for harming self or others may need to be isolated to help him or her feel safe by minimizing access to potentially harmful objects. Nurses need to be informed of potential side effects of medications in order to monitor for side effects and instructing others.

Rationale 4: A hallucination is a real experience to the individual To maintain a therapeutic relationship, the nurse should convey acceptance of the clients experience. Acknowledging disbelief of the auditory hallucination may affect the nurses ability to engage in a therapeutic nurseclient relationship. Clients who are low functioning may benefit from assistance with their activities of daily living, such as assisting with dressing. A client who is at risk for harming self or others may need to be isolated to help him or her feel safe by minimizing access to potentially harmful objects. Nurses need to be informed of potential side effects of medications in order to monitor for side effects and instructing others.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Analyze the personal characteristics you bring to the care of clients with schizophrenia that might cause you to distance yourself or fail to understand their experience and difficulties.

Question 29

Type: MCSA

Which answer choice, when placed in the blank, creates a correct statement?

The nurse maintaining a ______________ attitude will be more likely to understand the experiences and difficulties of a client with schizophrenia.

1. sympathetic

2. enmeshed

3. complementary

4. nonjudgmental

Correct Answer: 4

Rationale 1: The nurse maintaining a nonjudgmental attitude will be more likely to understand the experiences and difficulties of a client with schizophrenia. Being sympathetic, becoming enmeshed, or maintaining a complementary attitude are nontherapeutic interventions and will negatively affect the nurseclient relationship.

Rationale 2: The nurse maintaining a nonjudgmental attitude will be more likely to understand the experiences and difficulties of a client with schizophrenia. Being sympathetic, becoming enmeshed, or maintaining a complementary attitude are nontherapeutic interventions and will negatively affect the nurseclient relationship.

Rationale 3: The nurse maintaining a nonjudgmental attitude will be more likely to understand the experiences and difficulties of a client with schizophrenia. Being sympathetic, becoming enmeshed, or maintaining a complementary attitude are nontherapeutic interventions and will negatively affect the nurseclient relationship.

Rationale 4: The nurse maintaining a nonjudgmental attitude will be more likely to understand the experiences and difficulties of a client with schizophrenia. Being sympathetic, becoming enmeshed, or maintaining a complementary attitude are nontherapeutic interventions and will negatively affect the nurseclient relationship.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Analyze the personal characteristics you bring to the care of clients with schizophrenia that might cause you to distance yourself or fail to understand their experience and difficulties.

Question 30

Type: MCSA

Which of the following indicates sensitivity toward a client with schizophrenia?

1. Reporting a clients compliance with medication to the psychiatrist

2. Providing privacy for the client to visit with his or her family

3. Eating in the dining room with the clients

4. Providing encouragement for a client to attend groups

Correct Answer: 2

Rationale 1: Providing privacy for the client to visit with his or her family demonstrates that the nurse is being sensitive to the clients right to privacy. Providing encouragement for a client to attend group is a therapeutic intervention to prevent social isolation, not sensitivity. Eating in the dining room with the clients is an example of the nurse modeling positive social skills, not sensitivity. Reporting a clients compliance with medication to the psychiatrist is appropriate but is not an example of sensitivity.

Rationale 2: Providing privacy for the client to visit with his or her family demonstrates that the nurse is being sensitive to the clients right to privacy. Providing encouragement for a client to attend group is a therapeutic intervention to prevent social isolation, not sensitivity. Eating in the dining room with the clients is an example of the nurse modeling positive social skills, not sensitivity. Reporting a clients compliance with medication to the psychiatrist is appropriate but is not an example of sensitivity.

Rationale 3: Providing privacy for the client to visit with his or her family demonstrates that the nurse is being sensitive to the clients right to privacy. Providing encouragement for a client to attend group is a therapeutic intervention to prevent social isolation, not sensitivity. Eating in the dining room with the clients is an example of the nurse modeling positive social skills, not sensitivity. Reporting a clients compliance with medication to the psychiatrist is appropriate but is not an example of sensitivity.

Rationale 4: Providing privacy for the client to visit with his or her family demonstrates that the nurse is being sensitive to the clients right to privacy. Providing encouragement for a client to attend group is a therapeutic intervention to prevent social isolation, not sensitivity. Eating in the dining room with the clients is an example of the nurse modeling positive social skills, not sensitivity. Reporting a clients compliance with medication to the psychiatrist is appropriate but is not an example of sensitivity.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Analyze the personal characteristics you bring to the care of clients with schizophrenia that might cause you to distance yourself or fail to understand their experience and difficulties.

Kneisl, Contemporary Psychiatric-Mental Health Nursing, 3/e Test Bank

Copyright 2012 by Pearson Education, Inc.

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