Concept 32: Psychosis My Nursing Test Banks

Concept 32: Psychosis

Test Bank

MULTIPLE CHOICE

1. A client previously diagnosed as psychotic expresses to the nurse that he is seeing spiders climbing up the walls in his room and he is concerned that they will get into his bed. The nurses best response to this behavior is to

a.

ignore his remarks.

b.

express doubt that there are spiders on the wall.

c.

ask the client if he also sees spiders in the day room.

d.

tell the client there are no spiders and he should stop worrying about it.

ANS: B

The client is experiencing visual hallucinations. Appropriate care for this client would not include reinforcing his hallucinations, being dismissive of him, or ignoring him. Expressing reasonable doubt is the correct answer.

REF: 334 OBJ: NCLEX Client Needs Category: Psychosocial Integrity

2. A client with schizophrenia has relapsed and has been identified as being in stage four of relapse. Behavior which is most consistent with this stage of relapse would include

a.

expressing feelings of anxiety.

b.

expressing feelings of being overwhelmed.

c.

bizarre behaviors and speech.

d.

presence of hallucinations.

ANS: D

Schizophrenic clients who relapse go through five stages. Correctly identifying which stage the relapsing client is in is important so that interventions can be specific to the behavior. Expressing feelings of anxiety would be part of stage two, expressing feelings of being overwhelmed would be part of stage one, and bizarre behaviors and speech would be part of stage three. Presence of hallucinations is consistent with stage four, psychotic disorganization.

REF: 334 OBJ: NCLEX Client Needs Category: Psychosocial Integrity

3. The nurse is planning discharge teaching for a patient taking clozapine (Clozaril). Which of the following is essential to include?

a.

Caution about sunlight exposure

b.

Reminder to call the clinic if fever, sore throat, or malaise develops

c.

Instructions regarding dietary restrictions

d.

A chart to record patient weight

ANS: B

Fever, sore throat, and malaise are symptoms of agranulocytosis, a serious side effect of taking clozapine. Weekly blood counts are necessary to monitor for the condition. Sunlight exposure is a risk for persons taking chlorpromazine hydrochloride (Thorazine). There are no dietary restrictions for persons taking clozapine. While weight gain may occur when taking antipsychotic medication, daily monitoring is not required.

REF: 334

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

4. The nurse is caring for a 32-year-old woman diagnosed with schizophrenia. The woman tells the nurse, The news on TV last night was all about me. This is an example of what kind of thought content?

a.

Thought insertion

b.

Thought broadcasting

c.

Magical thinking

d.

Ideas of reference

ANS: D

Thought insertion is a belief that others are placing thoughts in ones mind. Thought broadcasting is a belief that others can read ones thoughts. Magical thinking is a belief that ones thoughts can make an event happen. Ideas of reference refers to a persons belief that external events, like the evening news, have a direct personal reference to oneself.

REF: 333 OBJ: NCLEX Client Needs Category: Psychosocial Integrity

MULTIPLE RESPONSE

1. A 23-year-old male veteran of the war in Iraq is admitted with a diagnosis of posttraumatic stress disorder (PTSD) following his arrest for destroying his girlfriends apartment. This is not his first angry outburst resulting in destruction of property. Which interventions by the nurse will be most helpful to this patient? (Select all that apply.)

a.

Allow opportunities for him to express his anger.

b.

Provide patient and family teaching regarding PTSD.

c.

Tell the patient that hurting himself will solve nothing.

d.

Report him to the authorities.

e.

Exhibit a nonjudgmental attitude.

f.

Reassure him that everything will be all right.

ANS: A, B, E

Allowing appropriate opportunities for him to express his anger will help him learn how to control his emotions or express them in a socially acceptable manner. Providing education to the patient and family will help them learn why he behaves the way he does and how to prevent or redirect his anger. Options C, D, and F are nontherapeutic in that they undermine the nurse-patient relationship. Being nonjudgmental in interactions with patients is a basic tenet of developing a therapeutic relationship.

REF: 334-335

OBJ: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

2. In discussing disease prevention with a 15-year-old boy and his mother, the nurse identifies which of the following as risk factors for psychosis? (Select all that apply.)

a.

Father diagnosed with paranoid schizophrenia

b.

Rural residence

c.

Recent immigration from Ecuador

d.

Occasional cannabis use

e.

January birth date

f.

Physical abuse by the father

ANS: A, C, E, F

Genetic predisposition has been identified as a risk factor for development of schizophrenia. Immigration, winter birth, and family difficulties such as abuse have also been identified as risk factors. Urban residence, not rural, and chronic cannabis use, not occasional, have also been identified.

REF: 331 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

3. Clients who are psychotic because of underlying psychiatric illness are treated with antipsychotic medications. Typical antipsychotic medications can improve positive symptoms in clients with schizophrenia. Positive symptoms include which of the following? (Select all that apply.)

a.

Hallucinations

b.

Disorganized speech and behavior

c.

Anhedonia

d.

Delusions

e.

Agitation

ANS: A, D, E

Positive symptoms of schizophrenia include the distortion or exaggeration of normal behavior, such as when the client experiences hallucinations, delusions, or agitation. Negative symptoms are those that cause a loss of normal function, such as when the client exhibits disorganized speech and behavior and anhedonia.

REF: 329-330 OBJ: NCLEX Client Needs Category: Psychosocial Integrity

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