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PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 12-18, 19

MSC: Client Needs: Psychosocial Integrity

TOP: Nursing Process: Assessment

30. A patient diagnosed with schizophrenia anxiously says, “I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror.” While listening, the nurse should a. sit close to the patient. b. place an arm protectively around the patient’s shoulders. c. place a hand on the patient’s arm and exert light pressure. d. maintain a normal social interaction distance from the patient.

ANS: D

The patient is describing phenomena that indicate personal boundary difficulties and depersonalization. The nurse should maintain appropriate social distance and not touch the patient because the patient is anxious about the inability to maintain ego boundaries and merging or being swallowed by the environment. Physical closeness or touch could precipitate panic.

PTS: 1

DIF: Cognitive Level: Apply (Application)

REF: Pages 12-20, 33 (Case Study and Nursing Care Plan: Schizophrenia), 74 (Table 12-3) TOP: Nursing Process: Implementation

MSC: Client Needs: Psychosocial Integrity a. “How long has the voice been directing your behavior?” b. “Does what the voice tell you to do frighten you?” c. “Do you recognize the voice speaking to you?’ d. “What is the voice telling you to do?”

31. A patient diagnosed with schizophrenia anxiously tells the nurse, “The voice is telling me to do things.” Select the nurse’s priority assessment question.

ANS: D

Learning what a command hallucination is telling the patient to do is important because the command often places the patient or others at risk for harm. Command hallucinations can be terrifying and may pose a psychiatric emergency. The incorrect questions are of lesser importance than identifying the command.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 12-23, 72 (Table 12-2), 74 (Table 12-3), 95 (Box 12-3)

TOP: Nursing Process: Assessment

MSC: Client Needs: Safe, Effective Care Environment a. Agranulocytosis; institute reverse isolation. b. Tardive dyskinesia; withhold the next dose of medication. c. Cholestatic jaundice; begin a high-protein, high-cholesterol diet. d. Neuroleptic malignant syndrome; notify health care provider stat.

32. A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 1030. By 1200, the patient has difficulty swallowing and is drooling. By 1600, vital signs are 102.8° F; pulse 110; respirations 26; 150/90. The patient is diaphoretic. Select the nurse’s best analysis and action.

ANS: D

Taking an antipsychotic medication coupled with the presence of extrapyramidal symptoms, such as severe muscle stiffness and difficulty swallowing, hyperpyrexia, and autonomic symptoms (pulse elevation), suggest neuroleptic malignant syndrome, a medical emergency. The symptoms given in the scenario are not consistent with the medical problems listed in the incorrect options.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

REF: Pages 12-55, 85 (Table 12-6) | Pages 12-219, 12-220

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity a. “The table of contents tells what a book is about.” b. “You can’t judge a book by looking at the cover.” c. “Things are not always as they first appear.” d. “Why are you asking me about books?”

33. A nurse asks a patient diagnosed with schizophrenia, “What is meant by the old saying ‘You can’t judge a book by looking at the cover.’?” Which response by the patient indicates concrete thinking?

ANS: A

Concrete thinking refers to an impaired ability to think abstractly. Concreteness is often assessed through the patient's interpretation of proverbs. Concreteness reduces one's ability to understand and address abstract concepts such as love or the passage of time. The incorrect options illustrate echolalia, an unrelated question, and abstract thinking.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 12-25 TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

34. The nurse is developing a plan for psychoeducational sessions for a small group of adults diagnosed with schizophrenia. Which goal is best for this group? Members will a. gain insight into unconscious factors that contribute to their illness. b. explore situations that trigger hostility and anger. c. learn to manage delusional thinking. d. demonstrate improved social skills.

ANS: D

Improved social skills help patients maintain relationships with others. These relationships are important to management of the disorder. Most patients with schizophrenia think concretely, so insight development is unlikely. Not all patients with schizophrenia experience delusions.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

REF: Pages 12-42, 43, 74 (Table 12-3) TOP: Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance a. Tell the client, “Facebook is a safe website. You don’t need to worry about Homeland Security.” b. Tell the client, “You are in a safe place where you will be helped.” c. Administer a prn dose of an antipsychotic medication. d. Tell the client, “You don’t need to worry about that.”

35. A client says, “Facebook has a new tracking capacity. If I use the Internet, Homeland Security will detain me as a terrorist.” Select the nurse’s best initial action.

ANS: B

The patient is experiencing paranoia and delusional thinking, which leads to fear. Explaining that the patient is in a safe place will help relieve the fear. It is not therapeutic to disagree or give advice. Medication will not relieve the immediate concern.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

REF: Pages 12-20, 45, 46, 74 (Table 12-3), 99 (Box 12-4)

TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity a. Hostility b. Bizarre behavior c. Poverty of thought d. Auditory hallucinations

36. Which finding constitutes a negative symptom associated with schizophrenia?

ANS: C

Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning. The distracters are positive symptoms of schizophrenia. See relationship to audience response question.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 12-4, 17, 72 (Table 12-2) TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity a. Visual hallucinations b. Magical thinking c. Idea of reference d. Thought insertion

37. A patient insistently states, “I can decipher codes of DNA just by looking at someone.” Which problem is evident?

ANS: B

Magical thinking is evident in the patient’s appraisal of his own abilities. There is no evidence of the distracters.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 12-20 TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity a. Word salad b. Neologism c. Anhedonia d. Echolalia

38. A newly hospitalized patient experiencing psychosis says, “Red chair out town board.” Which term should the nurse use to document this finding?

ANS: A eBay: testbanks_and_xanax

Word salad is a jumble of words that is meaningless to the listener and perhaps to the speaker as well, because of an extreme level of disorganization.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 12-18 TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

Multiple Response

1. A nurse at the mental health clinic plans a series of psychoeducational groups for persons newly diagnosed with schizophrenia. Which two topics take priority? (Select all that apply.)

a. “The importance of taking your medication correctly” b. “How to complete an application for employment” c. “How to dress when attending community events” d. “How to give and receive compliments” e. “Ways to quit smoking”

ANS: A, E

Stabilization is maximized by adherence to the antipsychotic medication regimen. Because so many persons with schizophrenia smoke cigarettes, this topic relates directly to the patients’ physiological well-being. The other topics are also important but are not priority topics.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

REF: Pages 12-42, 43, 103 (Evidence Based Practice) (Box 12-6)

TOP: Nursing Process: Planning/Outcomes Identification

MSC: Client Needs: Health Promotion and Maintenance a. Risk for other-directed violence b. Disturbed thought processes c. Risk for loneliness d. Spiritual distress e. Social isolation

2. A patient diagnosed with schizophrenia was hospitalized after arguing with co-workers and threatening to harm them. The patient is aloof, suspicious, and says, “Two staff members I saw talking were plotting to kill me.” Based on data gathered at this point, which nursing diagnoses relate? (Select all that apply.)

ANS: A, B

Delusions of persecution and ideas of reference support the nursing diagnosis of disturbed thought processes. Risk for other-directed violence is substantiated by the patient’s feeling endangered by persecutors. Fearful individuals may strike out at perceived persecutors or attempt self-harm to get away from persecutors. Data are not present to support the other diagnoses.