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Mental Health Week 4, Cognition

Psychosis

Due
Feb 2, 2022 by 11:59 pm

Final Score

100%
111 out of 159 questions answered correctly

Completed on
Feb 10, 2022 10:27 am

Incorrect
(48)

Which type of delusion would the nurse chart about a client who says,
'I’ve figured out how foreign agents have infiltrated the news media.
Now they want to shut me up'?
Nihilistic

Persecution
 Control
Grandeur

Rationale
The nurse would chart about delusions of persecution. Thoughts of being pursued by
powerful agents because of one’s special attributes or powers are fixed false beliefs and
are referred to as delusions of persecution. There is no evidence to indicate that there are
nihilistic delusions of total or partial nonexistence. There is also no evidence to support
that external forces are controlling the client (delusions of control) or that the client
has false beliefs of being a famous figure (delusions of grandeur).

Which action by the nurse would be priority for a male client with a
history of schizophrenia who comes to the emergency department
accompanied by his spouse?
Observing and evaluating his behavior

Writing a plan of care for the mental health team

Obtaining a copy of the client’s past medical records

Meeting separately with his wife and exploring why he came to the hospital

Rationale
The priority action is to observe and evaluate his behavior. The client and his needs are
the priority, and assessment is the first step of the nursing process. Writing a plan of
care for the mental health team is done after a thorough assessment is completed. The
nurse must deal with the present, not the past. Although meeting separately with the
wife should be done, it is not the priority; it can be done at a later time.

Which medication may lead to bruxism?

Vilazodone
 Isocarboxazid

Clomipramine

Levomilnacipran

Rationale
Serotonin reuptake inhibitors and serotonin/norepinephrine reuptake inhibitors may
lead to bruxism. Levomilnacipran is a serotonin/norepinephrine reuptake inhibitor that
may cause bruxism. Vilazodone is an atypical antidepressant that does not cause
bruxism. Isocarboxazid is a monoamine oxidase inhibitor that does not cause bruxism.
Clomipramine is a tricyclic antidepressant that does not cause bruxism.

The nurse understands that which medications are considered typical

antipsychotics? Select all that apply. One, some, or all responses may
be correct.
Asenapine
Lurasidone

Aripiprazole
Thioridazine

Chlorpromazine

Rationale
First-generation antipsychotic medications also are known as typical/conventional
antipsychotics. Thioridazine and chlorpromazine are typical antipsychotics. Asenapine,
lurasidone, and aripiprazole are atypical antipsychotics, also known as second-
generation antipsychotics.

The nurse understands that which antipsychotic medications have the

highest risk of causing tardive dyskinesia? Select all that apply. One,
some, or all responses may be correct.
Some correct answers were not selected

Loxapine

Quetiapine
Haloperidol
Ziprasidone

Olanzapine

Rationale
First-generation antipsychotic medications such as loxapine and haloperidol may cause
tardive dyskinesia, an extrapyramidal reaction. Second-generation antipsychotic
medications such as quetiapine, ziprasidone, and olanzapine have a lower risk of
causing extrapyramidal reactions.

Which term or phrase would the nurse chart about thought processes to
describe a client with schizophrenia who says, 'Yes, it’s March. March is
Little Women. That’s literal, you know'?
Echolalia
Neologisms

Flight of ideas
Loose associations

Rationale
The nurse would chart that the client has loose associations. Loose associations are
thoughts that are presented with minimal logical connections and are common in
schizophrenia. Echolalia is the purposeless repetition of words spoken by others or
repetition of overheard sounds. Neologisms are new, meaningless words coined by the
client. Flight of ideas is the rapid skipping from one topic to another and is more
common in mania.

Test-Taking Tip: Do not panic while taking an exam! Panic will only increase your
anxiety. Stop for a moment, close your eyes, take a few deep breaths, and resume
review of the question.

Which medications would the nurse identify as used to treat generalized

anxiety disorder (GAD)? Select all that apply. One, some, or all
responses may be correct.
Some correct answers were not selected
Duloxetine

Venlafaxine
Clonazepam
Escitalopram

Clomipramine

Rationale
Duloxetine, venlafaxine, and escitalopram are antidepressants approved for the
treatment of GAD. Clonazepam and clomipramine are used to treat panic disorders.

Which approach would the nurse take for a client with hallucinations
who suddenly rises and shouts, 'Stop saying that. Who do you think you
are'?
Explaining to the client that ignoring the voices will make them disappear
Taking the client to the client’s room for a quiet place to think away from other
clients
 Telling the client that the voices are not heard by the nurse, then offering to
listen to music together
Pointing out to the client the inappropriateness of the behavior in a
nonthreatening, nonjudgmental manner

Rationale
The nurse would tell the client that the nurse does not hear the voices and then offer
to listen to music together. Telling the client that the nurse doesn’t hear the voices and
offering to listen to music together presents the reality of the situation and helps
distract the client during a threatening hallucination. Telling the client to simply
ignore the voices is not therapeutic. It will be difficult for the client to do this. Taking
the client to the client’s room encourages withdrawal and isolation and will not stop
the hallucination. Pointing out the inappropriateness of the client’s behavior will have
little effect on it and will not stop the hallucination.

Which action would the nurse take when caring for a client who is
experiencing a paranoid delusion?
Touch the client’s arm gently to convey concern.
Maintain eye contact when talking with the client.

Attempt to disprove the client’s delusional thoughts.

Speak softly when talking with others near the client.

Rationale
The nurse would maintain eye contact when talking with the client. Eye contact focuses
the client’s attention on the nurse; it also conveys caring and tells the client that the
nurse considers the client important. The nurse would respect the client’s personal
space; touching the client, particularly without warning, may reinforce suspicious
thoughts or precipitate agitation. Attempting to disprove the client’s delusional
thoughts is useless, because a delusion is real to the client. Whispering or laughing in
the presence of a paranoid delusional client may reinforce the delusional state and
further agitate the client.

STUDY TIP: When forming a study group, carefully select members for your group.
Choose students who have abilities and motivation similar to your own. Look for
students who have a different learning style than you. Exchange names, email
addresses, and phone numbers. Plan a schedule for when and how often you will
meet. Plan an agenda for each meeting. You may exchange lecture notes and discuss
content for clarity or quiz one another on the material. You could also create your own
practice tests or make flash cards that review key vocabulary terms.

Which medications are used as the first-line treatment for post-

traumatic stress disorder (PTSD)? Select all that apply. One, some, or all
responses may be correct.
Sertraline

Paroxetine

Phenelzine
Venlafaxine

Amitriptyline

Rationale
Sertraline and paroxetine are selective serotonin reuptake inhibitors that are approved
by the US Food and Drug Administration as a first-line treatment for PTSD. If these
medications are ineffective, the use of phenelzine, venlafaxine, or amitriptyline is
indicated.
The nurse understands that the use of chlorpromazine to treat
schizophrenia is contraindicated in which clients? Select all that apply.
One, some, or all responses may be correct.
Some correct answers were not selected

Clients with glaucoma

Clients with dynamic ileus

Clients with Parkinson disease

Clients with severe hypertension

Clients with prostatic hypertrophy

Rationale
Chlorpromazine is a first-generation antipsychotic medication that should be avoided
in clients with a history of Parkinson disease or severe hypertension. Clients with a
history of glaucoma, dynamic ileus, or prostatic hypertrophy should be prescribed
chlorpromazine with caution.

Which statements regarding the use of selegiline to treat depression are

true? Select all that apply. One, some, or all responses may be correct.
Some correct answers were not selected

Carbamazepine lowers selegiline levels.

Oxcarbazepine significantly raises the level of selegiline.

Oral forms of selegiline are approved for bipolar disease.

The most common adverse reaction of selegiline is a localized rash.

Transdermal selegiline is the only transdermal treatment for major depression.
Rationale
Oxcarbazepine significantly raises the level of selegiline and is contraindicated. The
most common adverse reaction of selegiline is a localized rash. Transdermal selegiline
is the first and only transdermal treatment for major depression. Carbamazepine raises
the level of selegiline. Oral forms of selegiline are approved to treat symptoms of
Parkinson disease.

A client on antipsychotic medication therapy develops parkinsonism.

Which medications would the nurse anticipate being beneficial for the
client? Select all that apply. One, some, or all responses may be
correct.
Some correct answers were not selected

Levodopa
Benztropine

Amantadine

Bromocriptine
Diphenhydramine

Rationale
Benztropine is a centrally acting anticholinergic medication that can be used to treat
symptoms of parkinsonism associated with antipsychotic medications. Amantadine is
also used to treat antipsychotic-induced parkinsonism. Diphenhydramine is another
centrally acting anticholinergic medication that can be used to treat symptoms of
antipsychotic-induced parkinsonism. Levodopa and direct dopamine agonists such as
bromocriptine should be avoided in antipsychotic-induced parkinsonism because
these medications activate dopamine receptors, which might counteract the beneficial
effects of antipsychotic treatment.

A client on duloxetine therapy ingests ibuprofen for pain relief. Which

adverse effect would the nurse anticipate with this combination of
medications?
Bleeding
Hepatotoxicity

Serotonin syndrome

Cardiac dysrhythmias

Rationale
Duloxetine is a serotonin and norepinephrine reuptake inhibitor. When nonsteroidal
anti-inflammatory drugs (such as aspirin) are consumed with duloxetine, a high risk of
bleeding may result. Hepatotoxicity occurs due to the consumption of alcohol with
duloxetine. Serotonin syndrome occurs when selective serotonin reuptake inhibitors
are consumed along with duloxetine. Cardiac dysrhythmias may occur when
sympathomimetics are taken with tricyclic antidepressants.

Test-Taking Tip: Identify option components as correct or incorrect. This may help you
identify a wrong answer.

A client who is diagnosed with delusional disorder says, 'My ex-

girlfriend is having affairs to re-create our relationship; that proves that
she wants to come back to me.' Which specific subtype is the client
experiencing?
Erotomanic
Somatic

Grandiose
Persecutory
Rationale
The client is expressing an erotomanic delusion; he believes that his former girlfriend
is still romantically interested in him. Somatic delusions concern preoccupation with
the body, including complaints of disfigurement, nonfunctioning body parts, insect
infestation, and presence of a serious illness. In a grandiose delusion, the client seeks a
position of power by expressing an exaggerated belief in her or his importance or
identity. Clients with persecutory delusions believe that they are being conspired
against, spied on, drugged, or poisoned.

Which response would the nurse make to a confused, hallucinating

client who says, 'My arms are turning to stone'?
'May I examine your arms?'

'When did this feeling first start?'

'That’s a rather unusual sensation.'

'It can be frightening to feel that way.'

Rationale
The nurse would respond, 'It can be frightening to feel that way.' Depersonalization
communication is the result of a high anxiety level; projecting empathy to the client
will facilitate exploration of concerns. The response 'May I examine your arms?' does
not acknowledge the frightening experience for the client and supports the client’s
hallucination. When the feeling started is irrelevant and indicates that the nurse also
believes the hallucination; the nurse must address what the client is feeling. The
response, 'That’s a rather unusual sensation,' belittles the client’s feelings and may
make establishment of a therapeutic relationship difficult.

Which action would the nurse take when caring for a client whose
behavior is characterized by pathologic suspicious delusions?
Protect the client from environmental stress.
 Help the client feel accepted by the staff on the unit.
Ask the client to explain the reasons for the feelings.

Assist the client to realize that the suspicions are unrealistic.

Rationale
The nurse would help the client feel accepted by the staff on the unit. Delusions are
protective and can be abandoned only when the individual feels secure and adequate.
Helping the client feel accepted by the staff is the only response directed at building
the client’s security and reducing anxiety. Protecting the client from environmental
stress is almost impossible. The client is unable to explain the reason for the feelings. A
client cannot be argued out of a delusion, even if they seem unrealistic.

Test-Taking Tip: Multiple-choice questions can be challenging, because students think

that they will recognize the right answer when they see it or that the right answer will
somehow stand out from the other choices. This is a dangerous misconception. The
more carefully the question is constructed, the more each of the choices will seem like
the correct response.

Which approach would the nurse use when after 2 days on the unit a
client with schizophrenia refuses to take a shower?
Have the staff give the client a shower.
Simply state that the client must shower now.
Point out that the client’s appearance is upsetting the other clients.

Gently ask whether the client would wash the hands and face if given a basin
of water.

Rationale
The nurse would gently ask whether the client would wash the hands and face if given
a basin of water. The client needs to feel comfortable in the environment before
establishing enough trust to undress for showering; the nurse’s statement allows the
client to make the decision. Having the staff give the client a shower or stating that the
client must shower now may add to the client’s anxiety and feelings of loss of control;
it may also worsen any delusional thoughts the client is having. Pointing out that the
client’s appearance is upsetting the other clients will not help the client’s self-image,
and the nurse cannot speak for others.

Which initial approach would the nurse use to establish a therapeutic

one-on-one relationship with a guarded, suspicious client diagnosed
with schizophrenia?
Casual and honest

Warm and friendly

Permissive and distant
Undemanding and watchful

Rationale
The nurse would take an approach of being casual and honest. Individuals who are
guarded and suspicious with schizophrenia are more apt to trust nurses who display
matter-of-fact, predictable behaviors. The warm and friendly approach is too
threatening to the individual with schizophrenia who is suspicious. The permissive and
distant approach may be perceived as a lack of interest; these behaviors tend to
reinforce a paranoid individual’s social withdrawal. Although undemanding may be
appropriate in the initial stages, watchful behavior on the part of the nurse reinforces a
client’s suspiciousness.

Test-Taking Tip: Do not panic while taking an exam! Panic will only increase your
anxiety. Stop for a moment, close your eyes, take a few deep breaths, and resume
review of the question.
A client who is taking haloperidol has developed tardive dyskinesia.
Which therapy is beneficial for the client?
Administering benzodiazepines

Providing anticholinergic therapy

Administering nonsteroidal anti-inflammatory drugs
Switching to other first-generation antipsychotic medications

Rationale
The long-term usage of first-generation antipsychotics such as haloperidol increases
the risk of tardive dyskinesia. The client should be treated with benzodiazepines. Any
anticholinergic medications should be discontinued in the client. Nonsteroidal anti-
inflammatory drugs may not be beneficial for the client. The client should not switch
to another first-generation antipsychotic because the risk of tardive dyskinesia would
remain; if a switch were to occur, it should be to something other than a first-
generation medication.

Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times
when four or five consecutive questions have the same letter or number for the correct
answer.

A client on antidepressant therapy develops hyponatremia. Which

medication may be responsible for the client’s electrolyte imbalance?
Phenelzine
Paroxetine
Imipramine

Amitriptyline
Rationale
Paroxetine is a selective serotonin reuptake inhibitor; side effects include
hyponatremia. Phenelzine is a monoamine oxidase inhibitor; side effects include
orthostatic hypotension. Imipramine and amitriptyline are tricyclic antidepressants;
side effects associated with these medications include dry mouth and blurred vision.

Test-Taking Tip: Identifying content and what is being asked about that content is
critical to your choosing the correct response. Be alert for words in the stem of the
item that are the same or similar in nature to those in one or two of the options .

The nurse advises the client to refrain from skin contact of the
prescribed liquid formulation. Which antipsychotic medication is
prescribed to the client?
Loxapine
Asenapine

Alprazolam
Chlorpromazine

Rationale
Antipsychotics are available in tablet, capsule, and liquid dosage forms. Liquid
formulations require special handling. Phenothiazines such as Chlorpromazine that are
formulated in liquid dosages require safety precautions while handling. The nurse
would advise the client to avoid contact with the skin to avoid dermatitis. Loxapine is
prescribed to clients with schizophrenia; it is available as an inhaled powder. Asenapine
is administered as a sublingual tablet. Alprazolam is an adjunctive medication used to
treat anxiety and promote sleep; this medication does not cause contact dermatitis.

Which intervention would the nurse implement for a client prescribed

haloperidol for schizophrenia?  Select all that apply. One, some, or all
responses may be correct.
 Using the gluteal site only
Administering the medication every 3 months
Shaking the medication vigorously before administering

Using the Z-track method for all irritation medications

When initiating, giving the first two injections using the deltoid site
Monitoring the client for excess sedation for 3 hours postinjection

Rationale
Using the Z-track method for all irritation medications decreases injection discomfort
by keeping the irritant below the surface of the skin where pain receptors are located.
The gluteal or deltoid site may be used with haloperidol. Haloperidol is given every 4
weeks. Olanzapine and paliperidone are shaken vigorously before injection. When
initiating paliperidone, the first two injections must be given deltoid. Clients taking
olanzapine must be monitored for excess sedation for 3 hours postinjection.

Which intervention would the nurse include in the plan of care for a
client being treated with lithium for bipolar disorder? Select all that
apply. One, some, or all responses may be correct.
Some correct answers were not selected
Monitoring blood levels

Assessing for slurred speech

Evaluating intake and output
Instructing the client to limit caffeine intake

Advising the client to use reliable birth control

Rationale
Lithium has a narrow therapeutic range, and the nurse would regularly monitor the
client’s lithium levels. Slurred speech can be a sign of toxicity in clients taking lithium.
Clients taking lithium long term often have polyuria (50% to 70%), which the nurse
can monitor for by assessing intake and output. Caffeine can alter the medication’s
effectiveness. Clients do not need to completely eliminate caffeine, but they would be
instructed to limit their intake. Lithium is a category D pregnancy risk medication; it
may cause fetal harm during the first trimester of pregnancy. Clients who could
become pregnant should be informed of the risks and advised to use reliable birth
control to prevent pregnancy.

Dystonia develops in a client receiving injections of fluphenazine

decanoate for schizophrenia. Which clinical manifestations would the
nurse document during the assessment? Select all that apply. One,
some, or all responses may be correct.
Some correct answers were not selected

Akathisia
Torticollis
Shuffling gait

Masklike facies
Oculogyric crisis

Rationale
Impaired or distorted muscle tone (dystonia) is a side effect of fluphenazine decanoate;
spasms of the neck that pull the head to the side (torticollis) are typical of dystonia.
Deviation and fixation of the eyes (oculogyric crisis) are typical of dystonia. The feeling
of restlessness and an urgent need for movement (akathisia) is not related to dystonia.
Shuffling gait is a symptom of pseudoparkinsonism. A masklike facies is also found in
pseudoparkinsonism.
The nurse is educating a client who is taking clozapine to treat
schizophrenia. Which adverse effect of clozapine would the nurse
emphasize as being important to report to the health care provider?
A high risk for falls
Inability to sit still
Temperature rise

Tardive dyskinesia

Rationale
The nurse would emphasize to the client that it is important to report a rise in body
temperature (fever) to the health care provider because clozapine can cause
agranulocytosis (diminished immunity), which can promote infection. The inability to
sit still (akathisia), tardive dyskinesia (involuntary repetitive body movements), and a
higher risk for falls are more common with typical antipsychotics because of
extrapyramidal side effects.

A client diagnosed with depression is prescribed phenelzine. The nurse

understands that which foods, if consumed along with this medication,
may cause a hypertensive crisis? Select all that apply. One, some, or all
responses may be correct.
Yogurt
Red wine

Cream cheese
Aged meat
Aged cheese
Rationale
Monoamine oxidase inhibitors (MAOIs) including phenelzine may cause hypertensive
crisis if the client concurrently consumes foods rich in tyramine. Red wine, aged meat,
and aged cheese contain high amounts of tyramine. Yogurt and cream cheese have low
tyramine content and are considered permissible.

A client with post-traumatic stress disorder (PTSD) is prescribed a

selective serotonin reuptake inhibitor (SSRI). During a follow-up visit,
the nurse finds the symptoms have not subsided. The nurse
understands that which other medications would be beneficial for the
client? Select all that apply. One, some, or all responses may be
correct.
Buspirone
Phenelzine
Trazodone

Mirtazapine
Imipramine

Rationale
SSRIs are first-line agents used to treat PTSD. If SSRIs are not effective, then
monoamine oxidase inhibitors (such as phenelzine or mirtazapine) or a tricyclic
antidepressant (such as imipramine) may be effective in treating PTSD. Buspirone and
trazodone are not used to treat PTSD.

The nurse suspects serotonin syndrome in a client prescribed second-

generation antidepressants for depression. Which assessment findings
observed by the nurse would be beneficial in rating the severity of the
syndrome? Select all that apply. One, some, or all responses may be
correct.
Some correct answers were not selected

Delirium
Hyperreflexia
Hyperthermia

Muscle spasms
Rhabdomyolysis

Rationale
Serotonin syndrome is a potentially hazardous adverse effect of second-generation
antidepressants that are used to treat depression. Hyperthermia and rhabdomyolysis
are symptoms observed in severe cases of serotonin syndrome. Delirium,
hyperreflexia, and muscle spasms are common symptoms of this syndrome.

The nurse understands that clients with certain conditions who are
given haloperidol must be monitored for additional adverse reactions.
Which client conditions would warrant additional monitoring? Select all
that apply. One, some, or all responses may be correct.
Some correct answers were not selected

Glaucoma
Coma
Adynamic ileus

Parkinson disease
Prostatic hypertrophy
Rationale
Haloperidol is a first-generation antipsychotic medication. Clients with glaucoma
should use the medication with caution. Adynamic ileus may cause paralysis to
intestinal motility; the medication should be cautiously used in this client. Those with
prostatic hypertrophy should be given haloperidol with caution because prostatic
hyperplasia is a side effect of haloperidol. The medication is contraindicated in
comatose clients and those with Parkinson disease.

The nurse is caring for a 60-year-old client diagnosed with dementia.

The nurse understands that which antipsychotic medications would be
contraindicated for the client? Select all that apply. One, some, or all
responses may be correct.
Some correct answers were not selected
Quetiapine

Haloperidol
Aripiprazole
Risperidone

Chlorpromazine

Rationale
First-generation antipsychotic medications such as haloperidol and chlorpromazine are
contraindicated because they may increase the risk of mortality when used to treat
dementia-related psychosis in older adults. Quetiapine, aripiprazole, and risperidone
are second-generation antipsychotic medications that are not contraindicated in older
adults suffering from dementia-related psychosis.

A client with social anxiety disorder has a history of exhibiting an

intense, irrational fear of being scrutinized by others. Which primary
anxiolytic medications would the nurse anticipate developing a teaching
plan for? Select all that apply. One, some, or all responses may be
correct.
Some correct answers were not selected
Sertraline

Paroxetine
Alprazolam
Venlafaxine

Clonazepam

Rationale
Manifestations of social anxiety disorder include stuttering, sweating, palpitations, dry
throat, and muscle tension. Clients with this disorder exhibit an intense, irrational fear
of being scrutinized by others. Alprazolam and clonazepam are benzodiazepines that
are well tolerated in clients, and the benefits are immediate. Sertraline and paroxetine
are selective serotonin reuptake inhibitors that are also used in the treatment of social
anxiety disorder, but they do not act quickly. Venlafaxine is used to treat posttraumatic
stress disorder.

A client reports to the nurse, 'I’m afraid of every little thing and I have a
fear of dying. My heart races all the time, and I break out in sweats.'
Which first-line medications would the nurse anticipate developing a
teaching plan for? Select all that apply. One, some, or all responses
may be correct.
Some correct answers were not selected
Sertraline
Fluoxetine

Phenelzine
 Alprazolam
Imipramine

Rationale
A fear of every small thing, a fear of dying, palpitations, racing heartbeat, and sweating
are manifestations of a panic disorder. Selective serotonin reuptake inhibitors such as
sertraline and fluoxetine are first-line agents used to treat panic disorders. Phenelzine
is a monoamine oxidase inhibitor (MAOI) that is a last-line treatment in a panic
disorder. Alprazolam is a benzodiazepine and a second-line treatment for a panic
disorder. Imipramine is a tricyclic antidepressant used as a second-line treatment for a
panic disorder.

A health care provider prescribes clozapine to a client with

schizophrenia. Which parameters would the nurse assess before
administering the medication? Select all that apply. One, some, or all
responses may be correct.
Prolactin levels

Body mass index

White blood cell count

Serum potassium levels

Absolute neutrophil count

Rationale
Clozapine is a second-generation antipsychotic medication that may lead to
agranulocytosis. The white blood cell count and the absolute neutrophil count should
be tested for normal levels before administering the medication. Because this
medication may lead to weight gain, a baseline body mass index should be calculated
before initiating the therapy and at every visit for 6 months. Risperidone may increase
the prolactin levels and lead to gynecomastia and galactorrhea. The serum potassium
levels should be assessed before administering first-generation antipsychotics.

Test-Taking Tip: Read the question carefully before looking at the answers: (1)
determine what the question is really asking; look for key words; (2) read each answer
thoroughly and see if it completely covers the material asked by the question; (3)
narrow the choices by immediately eliminating answers you know are incorrect.

A client says, 'My legs are turning to rubber because I have an incurable
disease called schizophrenia.' Which alteration in perception is the client
experiencing?
Hallucination

Illusion
Depersonalization

Derealization

Rationale
The state in which the client feels unreal or believes that parts of the body are distorted
is known as depersonalization or loss of personal identity. This is not an example of a
hallucination; a hallucination is a sensory experience for which there is no external
stimulus. An illusion is a misinterpretation of an external stimulus. Derealization is the
feeling that the environment has changed (e.g., room is bigger or smaller than before).

A client says, 'There has been a lot of stress relation.' Which term
describes the client’s speech pattern?
Echolalia

Anamnesis
Neologism

Clang association
Rationale
A neologism is a made-up word used by a client that has a private meaning for the
client and cannot be understood by others. Echolalia is the pathological repeating of
another’s words. Anamnesis is the recollection of bygone events. Clang association is a
string words that have a similar sound or rhythm (e.g., clack, quack, jack).

A client has delusions and hallucinations and refers to himself as 'the

man.' He tells the nurse, 'The man is bad.' Which defense mechanism is
the client demonstrating?
Dissociation
Splitting

Displacement

Identification

Rationale
Speaking in the third person reflects poor ego boundaries and dissociation from the
real self. Splitting is the inability to integrate qualities of self or others into a cohesive
image. Displacement is an attempt to reduce anxiety by transferring the emotions
associated with one object or person to another. Identification is an attempt to increase
self-esteem by acquiring the attributes or characteristics of an admired individual.

Test-Taking Tip: Practicing a few relaxation techniques may prove helpful on the day of
an examination. Relaxation techniques such as deep breathing, imagery, head rolling,
shoulder shrugging, rotating and stretching of the neck, leg lifts, and heel lifts with
feet flat on the floor can effectively reduce tension while causing little or no distraction
to those around you. It is recommended that you practice 1 or 2 of these techniques
intermittently to avoid becoming tense. The more anxious and tense you become, the
longer it will take you to relax.

Which action would the nurse take to establish a trusting relationship

with a client who is using paranoid ideation?
Being available on the unit but waiting for the client to approach

Seeking the client out frequently to spend long blocks of time together

Sitting on the unit and observing the client’s behavior throughout the day
Calling the client into the office to establish a contract for regular therapy
sessions

Rationale
The nurse would be available on the unit but wait for the client to approach. The
recommended approach for working with suspicious clients is to allow them to set the
pace of the relationship. It is less threatening if they are the ones to initiate contact.
Seeking the client out frequently to spend long blocks of time together, sitting and
observing the client, and calling the client into the office may all be perceived as
threatening and may add to feelings of paranoia.

Which initial action would the nurse take for a schizophrenic client who
is seen pacing in the hall alone and talking loudly after a visit from
family members?
Obtain a prescription for a tranquilizer.

Ask the client about the events of the day.

Call the parents to find out what happened.

Assign an unlicensed assistive personnel to stay with the client.

Rationale
Initially, the nurse would ask the client about the events of the day. A broad opening
encourages communication that may elicit the client’s perception of the day’s events.
Obtaining a prescription for a tranquilizer is premature. What is most important is the
client’s, not the parents’, perception of what has occurred. Assigning an unlicensed
assistive personnel to stay with the client is premature; there are no data to indicate
that the client may self-harm or harm others.

Which response would the nurse make to a client with schizophrenia

who says, 'I know they’re spying on me in here, too. I’m not safe
anywhere'?
'Nobody’s spying on you in here.'

'Why do you feel they’d want to follow you here?'

'You don’t feel safe anywhere, not even in the hospital?'

'You’re safe in the hospital; nothing can happen to you here.'

Rationale
The nurse would say, 'You don’t feel safe anywhere, not even in the hospital?'
Rephrasing facilitates further communication, helps the nurse express understanding,
and does not belittle the client’s feelings. Confronting the client ('Nobody’s spying on
you in here') at this time will only increase the client’s anxiety and lead the client to
defend the delusion. 'Why' questions make a client defensive, and the wording implies
that the client’s delusion is true. Saying the client is safe and nothing can happen
constitutes false reassurance; also, a suspicious client will not believe the nurse.

Which response would the nurse make to a young adult client who
draws a face with horns and says, 'This is me. I’m a devil'?
'I don’t see a devil; why do you see a devil?'
'Let’s go to the mirror to see what you look like.'

'When I look at you I see a person, not a devil.'

'You’re not a devil; why do you talk about yourself like that?'
Rationale
The response 'When I look at you, I see a person, not a devil' points out reality while
attempting to let the client understand that the nurse sees the client as a person of
worth. The statement 'I don’t see a devil; why do you see a devil?' asks the client to
explain his or her feelings, which may be unrealistic; asking a client 'why' places the
client on the defensive and should be avoided. The statement 'Let’s go to the mirror to
see what you look like' is offensive and challenging. The client may indeed view him or
herself as a devil, even while looking in the mirror. The response 'You’re not a devil;
why do you talk about yourself like that?' is a somewhat belittling response; it cuts off
communication and asks 'why,' which is nontherapeutic.

Test-Taking Tip: Calm yourself by closing your eyes, putting down your pencil (or
computer mouse), and relaxing. Deep-breathe for a few minutes (or as needed, if you
feel especially tense) to relax your body and to relieve tension.

Which initial action would the nurse take for a college student who has
been talking to unseen people and refusing to get out of bed, go to
class, or participate in daily grooming activities?
Provide frequent rest periods.

Reduce environmental stimuli.

Facilitate the client’s social relationships with a peer group.

Attempt to establish a meaningful relationship with the client.

Rationale
The initial action the nurse would take is establishment of a meaningful relationship,
because it is through this relationship that the client can be helped. This client is not
getting out of bed; rest periods are not needed. The client has already reduced
environmental stimuli by staying in bed; further reduction is not needed. Establishing
social relationships with a peer group is a long-term goal.
Which action would the nurse take for a client with paranoid ideation?
Avoid placing demands on the client.
Eliminate stress so that the client can relax.

Give the client difficult tasks to provide stimulation.

Provide the client with opportunities for nonthreatening social interaction.

Rationale
The nurse would provide opportunities for nonthreatening social interaction.
Interacting in nonthreatening social situations will help reduce the use of paranoid
ideation. Because people must function in a social environment, it is almost
impossible to avoid placing some demands on the client. It is impossible to eliminate
stress so the client can relax, and this is nontherapeutic because the client has to learn
to cope with stress. Giving the client difficult tasks to provide stimulation will support
the client’s ideas of persecution and will lower the client’s self-esteem.

Which action would the nurse take next for a client who is experiencing
a relapse of psychotic symptoms but having no command
hallucinations?
Teach the client how to prevent relapses.

Instruct the client to eliminate dietary stimulants.

Help the client learn strategies for disregarding the voices.

Assist the client in recognizing hallucinations when they occur.

Rationale
The nurse would assist the client in recognizing hallucinations when they occur. After
issues related to the safety of the client and others have been addressed (no presence
of command hallucinations), it is important for the client to recognize hallucinations
when they occur to determine the frequency of the hallucinations; this is the first step
toward enabling the client to gain insight, which is an essential step in controlling
hallucinations. Although the client will eventually be taught how to prevent relapses, it
is not the priority at this time. Instructing the client to eliminate dietary stimulants is
appropriate for clients who are agitated; no data indicate that this client is agitated.
The client would be taught strategies for disregarding the voices after the frequency
has been determined and acknowledged by the client.

Which intermediate outcome would the nurse add to the plan of care
for a paranoid male client who has unjustifiably accused his wife of
having many extramarital affairs?
'The client will develop faith in his wife.'
'The client will develop better self-control.'

'The client will develop feelings of self-worth.'

'The client will develop insight into his behavior.'

Rationale
The intermediate outcome is to develop feelings of self-worth. Helping the client
develop feelings of self-worth will reduce the client’s need to use pathological
defenses. Faith in his wife, or the lack thereof, is not the basic underlying problem,
merely a symptom of it. Self-control, or the lack thereof, is not the basic underlying
problem, merely a symptom of it. Insight can develop only when the need to use the
defense is reduced; this is a long-term goal.

Which assessment would be priority for a client with schizophrenia who

has paranoia?
Continuous pacing
Suspicious feelings

Lack of love for parents

 Disregard for the feelings of others

Rationale
The priority assessment is suspicious feelings. Suspicious feelings may interfere with
the development of a trusting nurse –client relationship. Also, a person who is
suspicious may protect himself or herself through the use of verbal or physical
aggression. Safety is a priority, as is the development of a therapeutic nurse –client
relationship. Continuous pacing is not a problem, because the nurse can accompany a
pacing client. Lack of love for parents is not an initial concern. Disregard for the
feelings of others is not an initial concern unless it jeopardizes the safety of others.
There are no data indicating that it is a safety issue.

Effective therapeutic communication would directly affect which

outcomes for a client who has schizophrenia? Select all that apply. One,
some, or all responses may be correct.
Becomes capable of part-time employment

Effectively expresses emotional and physical needs

Demonstrates wellness reflective of physical potential

Demonstrates an understanding of the mental health disorder

Recognizes the issues most important to managing this disorder

Rationale
Effective communication would affect the following: effectively expressing emotional
and physical needs, demonstrating an understanding of the mental health disorder,
and recognizing the issues most important to managing this disorder. Therapeutic
communication facilitates the exchange of information between the nurse and the
client that focuses on the client attaining health and wellness. This information can be
directed toward the client’s health needs, such as the effective expression of the client’s
physical and emotional needs, the understanding of the cause and prognosis of the
current mental health problem, and the recognition of issues important to the
management of the client’s health issues. The client’s ability to maintain part-time
employment and the client’s physical health potential are minimally affected by
therapeutic communication.

Which action would the nurse take for a client’s family who is worried
that the client will continue to act out at the halfway house?
Let the social worker talk with the family.
Cancel the discharge plans until the family is reassured.

Have the client promise the nurse and family not to act out.

Discuss the concern at a meeting with both the client and the family present.

Rationale
The best action to take is to discuss the concern at a meeting with both the client and
the family present. Discussing the concern at a meeting with both the client and the
family present gives the client and family an opportunity to discuss their feelings
together and clarifies their expectations. Talking with the family is the nurse’s
responsibility and should not be passed to someone else such as a social worker.
Canceling the discharge plans until the family is reassured is not the nurse’s role; the
family may never be reassured. Having the client promise the nurse and family that
acting out will not occur will do little to reassure the family.

Correct
(111)

The nurse understands which condition as being contraindicated for St.

John’s wort herbal therapy?
Anxiety

Seizures
 Dementia

Cardiac disease

Rationale
St. John’s wort is contraindicated for dementia; this herbal therapy is used to treat
anxiety. Bupropion therapy is contraindicated for seizures. Valerian (Valeriana officinalis)
is contraindicated for cardiac disease.

The nurse would identify which medication as the most common cause
of extrapyramidal side effects (EPSs)?
Clozapine
Haloperidol

Risperidone

Aripiprazole

Rationale
Haloperidol is a typical antipsychotic that commonly causes extrapyramidal side
effects. Clozapine is an atypical antipsychotic that has a low risk of causing
extrapyramidal side effects. Risperidone and aripiprazole have a low risk of causing
extrapyramidal side effects.

When providing a change-of-shift report, which explanation would the

nurse use to describe a schizophrenic client who is experiencing
opposing emotions simultaneously?
Double bind

Ambivalence
Loose association
 Inappropriate affect

Rationale
The nurse would use the term ambivalence to describe opposing emotions
simultaneously. Ambivalence is the existence of two conflicting emotions, impulses, or
desires. Double bind means having two conflicting messages, not emotions, in a
single communication. Loose associations are not two conflicting emotions but
instead the loosening of connections between thoughts. Inappropriate affect is the
incongruous expression of emotions when compared with behavior or content of
speech.

Which antidepressant medication is a selective monoamine oxidase-B

inhibitor?
Selegiline

Phenelzine

Isocarboxazid
Tranylcypromine

Rationale
Selegiline is a selective monoamine oxidase-B inhibitor. Phenelzine, isocarboxazid, and
tranylcypromine are nonselective monoamine oxidase-A and monoamine oxidase-B
inhibitors.

Which medication is indicated for treating obsessive-compulsive

disorder?
Imipramine
Lithium salts

Amitriptyline
 Clomipramine

Rationale
Clomipramine is a tricyclic antidepressant medication prescribed for treating
obsessive-compulsive disorder. Childhood enuresis necessitates the administration of
imipramine. Lithium salt is prescribed to treat bipolar disorders. Dysthymias can be
treated by the administration of antidepressant medications such as amitriptyline.

Which toxic effect would the nurse find in a client who has overdosed on
isocarboxazid?
Mydriasis

Bradycardia
Hypothermia

Circulatory collapse

Rationale
The clinical symptoms of monoamine oxidase inhibitors (MAOIs) generally appear after
12 hours of ingestion. Circulatory collapse is associated with MAOI toxicity. Mydriasis,
bradycardia, and hyperthermia are not associated with an isocarboxazid overdose.

Which statement is true regarding antipsychotic medications?

All first- and second-generation antipsychotics are equally effective.
Second-generation antipsychotics pose a risk of extrapyramidal symptoms.

First-generation antipsychotics pose a significant risk of metabolic side effects.

Clozapine is more effective than other second-generation antipsychotics.

Rationale
Clozapine is a second-generation antipsychotic medication that is more effective than
other second-generation antipsychotics. Most (but not all) first- and second-
generation antipsychotics are equally effective. Second-generation antipsychotics may
cause metabolic side effects such as diabetes and dyslipidemia. First-generation
antipsychotics may cause extrapyramidal side effects.

Which condition contraindicates the use of ginseng herbal therapy?

Pregnancy
Schizophrenia

Bipolar depression

Alzheimer disease

Rationale
Pregnancy is contraindicated for ginseng herbal therapy. Schizophrenia, bipolar
depression, and Alzheimer disease are contraindicated for St. John’s Wort herbal
therapy.

The nurse suspects that the client has shift-work sleep disorder (SWSD).
Which medication is indicated to treat this disorder?
Caffeine

Modafinil
Atomoxetine

Methylphenidate

Rationale
Modafinil is a unique nonamphetamine stimulant used to treat SWSD. This
medication promotes wakefulness in clients suffering from excessive sleepiness
associated with SWSD. Caffeine is a central nervous stimulant used to promote
wakefulness, but this medication is not as effective in the treatment of SWSD.
Atomoxetine is a nonstimulant used to treat attention-deficit/hyperactivity disorder
(ADHD). Methylphenidate is considered a first-choice medication for the treatment of
ADHD.

Which medication is the first choice of medication for the treatment of

attention-deficit/hyperactivity disorder (ADHD)?
Clonidine
Guanfacine

Atomoxetine

Methylphenidate

Rationale
Methylphenidate is the first choice of medication for the treatment of attention-
deficit/hyperactivity disorder (ADHD). Clonidine, guanfacine, and atomoxetine are
nonstimulants used to treat ADHD; these medications are less effective than
methylphenidate.

The nurse is caring for several clients with major thought disorders such
as those occurring in clients with schizophrenia. They are all being
treated with neuroleptic medications. How do these medications act in
the body to promote mental health?
They inhibit enzymes at the postsynaptic receptor site.

They decrease serotonin at the postsynaptic receptor site.

They increase dopamine uptake at the postsynaptic receptor site.
 They block access to dopamine receptors at the postsynaptic receptor site.

Rationale
Neuroleptics block access to dopamine receptors, rather than inhibiting enzymes, at
postsynaptic sites. They increase, not decrease, serotonin at postsynaptic sites.

The nurse concludes which as the major reason clients with severe
psychiatric disorders are prescribed antipsychotic medications?
Improvement of judgment
Promotion of social skills

Elimination of neurotic tendencies

Symptom management of psychosis

Rationale
Antipsychotics are a class of medications primarily used to manage signs and
symptoms associated with psychoses including hallucinations, delusions, paranoia,
and disorganized speech. These medications are used to minimize psychotic, not
neurotic, signs and symptoms. Improved judgment and social skills may be outcomes
related to managing the psychoses but are not prime reasons that antipsychotic
medications are prescribed.

The nurse understands that which second-generation antidepressant

can worsen uncontrolled angle-closure glaucoma?
Trazodone

Bupropion
Duloxetine

Mirtazapine
Rationale
Duloxetine can worsen uncontrolled angle-closure glaucoma. Trazodone is
contraindicated in clients with a known medication allergy. Bupropion is
contraindicated for clients with seizures. Mirtazapine is contraindicated in cases of
known medication allergy and concurrent use of monoamine oxidase inhibitors.

The nurse understands that clozapine is contraindicated in the client

with which condition?
Seizures
Glaucoma

Dysrhythmias

Bone marrow depression

Rationale
Clozapine is an atypical antipsychotic medication that is contraindicated in clients with
bone marrow depression. Clozapine should be used with caution in clients with
seizures. First-generation antipsychotics should be used with caution in clients with
glaucoma. Ziprasidone is contraindicated in clients with a history of dysrhythmias.

The nurse understands that which adverse effect is least likely to occur
in a client who is prescribed clozapine?
Seizures

Sedation
Akathisia

Myocarditis

Rationale
Clozapine is a second-generation antipsychotic medication. Myocarditis is a very rare
side effect of clozapine. Seizures, sedation, and akathisia are common side effects of
clozapine.

The nurse recognizes which atypical antipsychotics as being approved

for long-term use to prevent the recurrence of mood episodes in clients
with bipolar disease? Select all that apply. One, some, or all responses
may be correct.
Olanzapine
Quetiapine

Ziprasidone

Risperidone
Aripiprazole

Rationale
Olanzapine, ziprasidone, and aripiprazole are atypical antipsychotics approved for
long-term use to prevent recurrence of mood episodes. Quetiapine and risperidone
are atypical antipsychotics approved for use in bipolar disease but are not approved for
long-term use to prevent the recurrence of mood episodes.

The nurse recognizes which antidepressant is a second-generation

medication?
Doxepin

Citalopram
Protriptyline

Trimipramine
Rationale
Citalopram is an example of a second-generation antidepressant medication. Doxepin,
protriptyline, and trimipramine are examples of first-generation antidepressant
medications.

Which term describes the client’s use of made-up words that have no
meaning to other people?
Avolition

Echolalia
Anhedonia

Neologisms

Rationale
Neologisms are unique words with personal meanings only to the client. Avolition is
the lack of motivation associated with a reduced emotional expression (flat affect).
Echolalia is parrotlike echoing of spoken words or sounds. Anhedonia is the loss of
enjoyment of things that were formerly enjoyed.

Which type of hallucination is the most common?

Visual

Tactile
Auditory

Olfactory

Rationale
Most hallucinating clients hear voices without external stimuli. Although hallucinating
clients may see things without external stimuli, visual hallucinations are not as
common as auditory hallucinations. Tactile and olfactory hallucinations are not very
common.

At which point in the daily routine do clients who experience alterations

in perception tend to have more problems with vivid hallucinations?
Before meals

After going to bed

During group activities

While watching television

Rationale
After going to bed, auditory hallucinations are most troublesome because
environmental stimuli are diminished and there are few competing distractions.
Meals, group activities, and television provide relatively high and competing
environmental stimuli.

Which term would the nurse use to describe the thought processes of a
male client who insists that he is the commander of an alien spaceship
despite repeated reality orientation?
Illusion

Delusion
Confabulation

Hallucination

Rationale
The term the nurse would use is delusion. A delusion is a fixed false belief. An illusion is
a false sense interpretation of an external stimulus. Confabulation is the client’s
attempt to fill gaps in memory with imaginary events. A hallucination is a false sensory
perception with no external stimulus.

Test-Taking Tip: Read every word of each question and option before responding to
the item. Glossing over the questions just to get through the examination quickly can
cause you to misread or misinterpret the real intent of the question.

Which clinical manifestation would best indicate to the nurse that the
mental status of a client with schizophrenia and paranoid delusions is
improving?
Absence of mild to moderate anxiety
Development of insight into the problem

Decreased need to use defense mechanisms

Ability to function effectively in activities of daily living

Rationale
The ability to function effectively in activities of daily living would indicate
improvement. A person who can handle activities of daily living and function in society
is considered mentally stable. Some anxiety is necessary and unavoidable; anxiety
causes problems when it is overwhelming for an extended period. Insight into one’s
problems is of no use if one is unable to function. Everyone uses defense mechanisms;
the extent to which they are used helps determine mental health.

STUDY TIP: Focus your study time on the common health problems that nurses most
frequently encounter.

Which term would the nurse use to describe a client with schizophrenia
who is vacillating between being happy and sad about going home?
Double bind
 Ambivalence

Loose association
Inappropriate affect

Rationale
The term to describe a schizophrenic client who is vacillating between being happy and
sad about going home is ambivalence. The simultaneous existence of two conflicting
emotions, impulses, or desires is known as ambivalence. A single communication
containing two conflicting messages is known as a double-bind message. A lack of
connections between thoughts is known as loose association. Inappropriate affect is not
two conflicting emotions but instead the inappropriate expression of emotions.

Which factor would the nurse identify as likely related to the

sleeplessness of a schizophrenic client who was transferred from a
private room to a room with a roommate 3 days ago?
Fear of the other client
Concern about family at home

Watching for an opportunity to escape

Trying to work out emotional problems

Rationale
The nurse would consider that the schizophrenic client is fearful of the other client
because of the transfer from a private room to a room with a roommate. Concern
about family at home seems unlikely, because the disruption appears to have started
with the transfer to a room with a roommate. Watching for an opportunity to escape is
possible but unlikely; planning an escape is usually not part of a schizophrenic pattern
of behavior. Trying to work out emotional problems is possible but not likely; clients
with schizophrenia have difficulty solving problems.
Which response would the nurse make while speaking to a client with
schizophrenia who keeps interjecting sentences that have nothing to do
with the main thoughts being expressed?
'You aren’t making any sense; let’s talk about something else.'

'You’re so confused; I can’t understand what you’re saying to me.'

'Why don’t you take a rest? We can talk again later this afternoon.'
'I’d like to understand what you’re saying, but I’m having difficulty following
you.'

Rationale
The nurse would say, 'I’d like to understand what you are saying, but I’m having
difficulty following you.' This response lets the client know the nurse is trying to
understand; it increases the client’s self-esteem and points out reality. Clients with
schizophrenia have problems with associative links, and these same problems will
occur regardless of the topic; thus talking about something else is ineffective. The
statement, 'You’re so confused; I can’t understand what you’re saying to me,' cuts off
communication and blames the client. Using 'why' and suggesting talking about the
client’s concerns again later in the day cuts off communication by abruptly ending the
conversation, which is belittling to the client.

STUDY TIP: Answer every question. A question without an answer is the same as a
wrong answer. Go ahead and guess. You have studied for the test and you know the
material well. You are not making a random guess based on no information. You are
guessing based on what you have learned and your best assessment of the question.

Which action would the nurse take for a client with schizophrenia who
needs self-esteem increased?
Reward healthy behaviors.

Explain the treatment plan.

 Identify various means of coping.

Encourage participation in community meetings.

Rationale
The nurse would reward healthy behaviors. By realistically rewarding the healthy
behaviors, the nurse provides secondary gains, encourages the continued use of
healthy behaviors, and increases self-esteem. Explaining the treatment plan,
identifying various means of coping, and encouraging participation in community
meetings are important but will do little to increase the client’s self-esteem.

Which response would the nurse make to a client who says, 'I’m a
terrible, evil person. The voices are telling me that God needs to punish
me'?
'God is loving and won’t punish you.'

'Those voices you’re hearing are a fantasy.'

'Tell me what you’re thinking about yourself.'
'You aren’t wicked—both God and I love you.'

Rationale
The nurse would say, 'Tell me what you’re thinking about yourself.' Encouraging the
client to focus on the self will facilitate communication and foster self-perception.
Stating that God will not punish the client denies the client’s feelings, provides false
reassurance, and validates the hallucinations. Stating that the voices are fantasy denies
the client’s experience. Stating that the client is not wicked denies the client’s feelings
and provides false reassurance.

A client with schizophrenia is given an antipsychotic medication. The

nurse recalls all the extrapyramidal effects associated with this type of
medication and anticipates that the medication will be discontinued if
which adverse effect occurs?
Akathisia
Tardive dyskinesia

Parkinsonian syndrome
Acute dystonic reaction

Rationale
Tardive dyskinesia is characterized by protrusion and vermicular movements of the
tongue, chewing and puckering movements of the mouth, and a puffing of the cheeks.
These adverse effects may or may not be reversible when the antipsychotic medication
is withdrawn. Motor restlessness (akathisia), parkinsonian symptoms, or an acute
dystonic reaction can be treated with an antiparkinsonian or anticholinergic
medication while the antipsychotic medication is continued.

A client has been prescribed lithium. Which intervention must be

implemented while the client is on lithium therapy?
Restricting the client’s daily sodium intake

Testing the client’s urine specific gravity weekly

Regularly testing the serum medication level
Withholding the client’s other medications for several days

Rationale
Lithium alters sodium transport in nerve and muscle cells and causes a shift toward
intraneuronal metabolism of catecholamines. Because the range between therapeutic
and toxic levels is very slim, the client’s serum lithium level should be monitored
closely. Sodium restriction may cause electrolyte imbalance and lithium toxicity.
Weekly testing of the client’s urine specific gravity is not necessary or useful.
Withholding the client’s other medications for several days may or may not be
necessary; it depends on what the client is receiving; also, it requires a primary health
care provider’s prescription.

A client with a diagnosis of schizophrenia is prescribed an antipsychotic

medication. The nurse understands which side effect of antipsychotic
medications may be irreversible?
Akathisia
Tardive dyskinesia

Parkinsonian syndrome
Acute dystonic reaction

Rationale
Tardive dyskinesia, an extrapyramidal response characterized by vermicular movements
and protrusion of the tongue, chewing and puckering movements of the mouth, and
puffing of the cheeks, is often irreversible, even when the antipsychotic medication is
withdrawn. Akathisia (motor restlessness), parkinsonian syndrome (a disorder
featuring signs and symptoms of Parkinson's disease such as resting tremors, muscle
weakness, reduced movement, and festinating gait), and dystonia (impairment of
muscle tonus) usually can be treated with antiparkinsonian or anticholinergic
medications while the antipsychotic medication is continued.

The primary health care provider prescribes a neuroleptic medication to

a client diagnosed with schizophrenia. The nurse understands which to
be the reasoning the health care provider would choose this medication?
Symptoms
Side effects
Therapeutic effects
 Underlying pathology

Rationale
First-generation antipsychotic medications are also known as neuroleptics. The
selection of these medications is based more on side effects than therapeutic effects.
Because all symptoms respond equally to antipsychotic medications, the medication
selection may not be based on symptoms. Because these medications do not alter the
underlying pathology, the selection may not be based on underlying pathology.

A client says, 'Sky, flower, angry, green, opposite, blanket.' Which term
describes this type of communication?
Echolalia
Word salad

Confabulation
Flight of ideas

Rationale
Word salad is an incoherent mixture of words. Echolalia is a pathological repetition of
another’s words or phrases. Confabulation is the unconscious filling in of memory
gaps with imagined or untrue experiences. Flight of ideas is a speech pattern of rapid
transition from topic to topic.

A hostile client with the diagnosis of schizophrenia, says, 'The voices are
saying that they are going to poison me because I’m bad.' Which type of
schizophrenic behavior is the client displaying?
Residual

Paranoid
 Catatonic

Disorganized

Rationale
Clients with paranoid schizophrenia tend to experience persecutory or grandiose
delusions and auditory hallucinations and exhibit behavioral changes such as anger,
hostility, or violence. Residual schizophrenia is characterized by the negative symptoms
of schizophrenia, but the positive symptoms are usually absent or reduced. Catatonia
is a state in which the client displays extreme psychomotor retardation to the point of
not talking or moving. There may be brief intermittent hyperactive episodes with
catatonia. Disorganized schizophrenia is characterized by a disintegration of the
personality and withdrawn behavior.

Which type of delusion is a client displaying when he proclaims, 'I am

the second son of God'?
Influence
Religious

Reference
Persecutory

Rationale
The client is expressing a religious delusion: a belief that one is favored by a higher
being or is an instrument of that being. An influence delusion is a fixed false belief that
one has the power to control the thoughts of another. A reference delusion is a fixed
false belief that casual incidents and external events have direct personal references,
such as the television is sending special messages. A persecutory delusion is a fixed
false belief that one is being mistreated by others.

Test-Taking Tip: Monitor questions that you answer with an educated guess or ones
where you changed your answer from the first option you selected. This will help you
analyze your ability to think critically. Usually your first answer is correct and should
not be changed without reason.

Which action during the admission assessment would the nurse take for
an involuntary admitted client who says, 'I am the second son of God
and need to say a prayer'?
Interrupt the client and continue the assessment.
Join the client in the prayer and then refocus on the assessment.
Quietly leave the client and come back later to complete the assessment.

Wait until the client finishes the prayer and then complete the assessment.

Rationale
The nurse would wait until the client finishes the prayer and then complete the
assessment. During the initial assessment, it is important for the nurse to learn as
much as possible about a client and to establish baseline data; therefore, both direct
and indirect assessment data are important. Interrupting the client may interfere with
the nurse-client relationship and increase the client’s anxiety; also, it may interfere with
obtaining valuable information about the client. Joining the client in the prayer and
then refocusing on the assessment is not therapeutic and may reinforce the client’s
delusional thinking. Quietly leaving the client and returning later to complete the
assessment is not therapeutic, is not safe, and will not meet standards of care; it may
precipitate feelings of abandonment.

STUDY TIP: Identify your problem areas that need attention. Do not waste time on
restudying information you know.

Which approach would the nurse take for a client with schizophrenia
who refuses to get out of bed and becomes upset?
Requiring the client to get out of bed at once
 Allowing the client to stay in bed for a while
Staying at the bedside until the client calms down
Giving the prescribed as-needed tranquilizer to the client

Rationale
The nurse would stay at the bedside until the client calms down. This approach
provides support and security without rejecting the client or placing value judgments
on behavior. Eventually limits will have to be set (to get out of bed), but this is not the
immediate nursing action and it does not have to be at once. Allowing the client to
stay in bed for a while ignores the problem, and isolation may imply punishment.
Although medication will calm the client, it does not address the immediate problem
that requires support from the nurse.

STUDY TIP: Record the information you find to be most difficult to remember on 3' ×
5' cards and carry them with you in your pocket or purse. When you are waiting in
traffic or for an appointment, just pull out the cards and review again. This 'found' time
may add points to your test scores that you have lost in the past.

Which essential action would the nurse take for a client whose behavior
is characterized by suspicious delusions?
Provide distraction with reality-based activities.

Try to establish trust through consistency of care.

Help the client realize that the suspicions are unrealistic.
Ask the client to explain the reasons for these suspicions.

Rationale
The essential action is to establish trust through consistency of care. Delusions are
protective and can be abandoned only when the individual feels secure and adequate;
as the client’s sense of security increases, the client’s anxiety will decrease. Providing
distraction with reality-based activities is more helpful in regard to hallucinations than
delusions. Before the client can realize that the suspicions are unrealistic, trust must
be developed and the client’s anxiety eased. The client will be unable to explain the
reason for the feelings.

Which immediate action would the nurse take for an adolescent boy
with schizophrenia who exposes his genitals to a nurse?
Ignore the client at this time.

State that this behavior is unacceptable.

Move him to his room for a short time-out.
Tell the client to come to the office later to discuss the behavior.

Rationale
The nurse would immediately state that his behavior is unacceptable. When clients
enter a new milieu, limits should be set on unacceptable behavior and acceptable
behavior should be reinforced. Neither clients nor unacceptable behavior should be
ignored. Moving the client to his room for a short time-out is punishment.
Unacceptable attention-getting behavior must be addressed immediately; also, the
focus should be on appropriate behavior.

Test-Taking Tip: If the question asks for an immediate action or response, all of the
answers may be correct, so base your selection on identified priorities for action.

Which action would the nurse take for a newly admitted client with
schizophrenia who refuses to remove dirty clothing?
Allow the client to undress when ready to help maintain identity.

Provide two outfits and help the client decide which one to wear.
Explain that clean clothes will look more attractive and increase self-esteem.
 Get assistance to remove the clothing to meet the client’s basic hygiene needs.

Rationale
The nurse would allow the client to undress when ready to help maintain identity. Any
approach other than allowing the client to undress when ready will probably be seen as
threatening, increase anxiety, and result in a physical confrontation. Providing two
outfits and helping the client make a simple decision will increase anxiety, not foster
decision-making. Explaining that clean clothes will look more attractive and increase
self-esteem will increase anxiety, not increase self-esteem. Getting assistance and
removing the clothing to meet the client’s basic hygiene needs will increase the client’s
anxiety and will probably result in a physical confrontation.

A client with schizophrenia who has type II (negative) symptoms is

prescribed risperidone. Which outcomes indicate the medication has
minimized these symptoms? Select all that apply. One, some, or all
responses may be correct.
There is less agitation.
There are fewer delusions.

More interest is shown in unit activities.

The client reports that the hallucinations have stopped.
The client performs activities of daily living independently.

Rationale
Apathy is a common type II (negative) symptom; flat affect and lack of socialization are
also common. Increased interest in unit activities indicates minimized symptoms. A
lack of interest in performing daily self-care is a common type II (negative) symptom;
performing activities of daily living independently represents a reduction in this
symptom. Interest in unit activities is a type I (positive) symptom. Delusions and
hallucinations are type I (positive) symptoms.

The nurse finds that a child has inattention, hyperactivity, and

impulsivity upon assessment. The nurse anticipates which medication to
be most beneficial for the child?
Modafinil
Doxapram

Armodafinil
Atomoxetine

Rationale
Inattention, hyperactivity, and impulsivity in a child may indicate that the child has
attention-deficit/hyperactivity disorder (ADHD). Atomoxetine is a nonstimulant
second-line medication used to treat ADHD. Modafinil, doxapram, and armodafinil are
nonamphetamine stimulants used to treat shift-work sleep disorder (SWSD).

A client diagnosed with schizophrenia was prescribed antipsychotic

medications and developed extrapyramidal symptoms. The nurse
understands which medications might be responsible for these
symptoms? Select all that apply. One, some, or all responses may be
correct.
Clozapine
Olanzapine

Perphenazine
Fluphenazine
Trifluoperazine
Rationale
Perphenazine, fluphenazine, and trifluoperazine are first-generation antipsychotic
medications with a high risk of extrapyramidal symptoms. Second-generation
antipsychotic medications such as clozapine and olanzapine have a lower risk of
extrapyramidal symptoms.

The health care provider prescribes an atypical antipsychotic medication

to a client and asks the nurse to set up an appointment with an
ophthalmologist. Which medication was prescribed to the client?
Clozapine
Quetiapine

Ziprasidone
Chlorpromazine

Rationale
Quetiapine is a second-generation antipsychotic medication that may pose a risk of
cataracts. The prescriber would refer the client to an ophthalmologist for an
examination of the lenses. Clozapine is a second-generation antipsychotic medication
that does not carry any risk of cataracts. Ziprasidone may cause alterations in the QT
intervals. Chlorpromazine is a first-generation antipsychotic medication that does not
cause cataracts.

Test-Taking Tip: You have at least a 25% chance of selecting the correct response in
multiple-choice items. If you are uncertain about a question, eliminate the choices that
you believe are wrong and then call on your knowledge, skills, and abilities to choose
from the remaining responses.

The nurse understands that which medication would be used to treat a

client with severe motor tics, barking cries, and outbursts of obscene
language?
 Loxapine
Pimozide
Thiothixene

Thioridazine

Rationale
Severe motor tics, barking cries, and outbursts of obscene language are signs of
Tourette syndrome. Pimozide is a high-potency medication used to treat this
syndrome. Loxapine is a medium-potency agent indicated only for schizophrenia.
Thiothixene is a high-potency agent indicated for schizophrenia. Thioridazine is a low-
potency, first-generation antipsychotic indicated for schizophrenia.

Which medication would the nurse administer transdermally to treat a

client with major depression?
Selegiline
Phenelzine

Isocarboxazid
Tranylcypromine

Rationale
Selegiline is a selective monoamine oxidase inhibitor-B (MAOI-B) that comes in a
transdermal dosage form; this medication is used in the management of major
depression. Phenelzine, isocarboxazid, and tranylcypromine are nonselective inhibitors
of both MAOI type A and MAOI type B. These medications are administered orally.

The client is mute, immobile, unresponsive to questions, and appears

unaware of the surroundings. Which term describes these symptoms?
 Alogia
Catatonia

Echopraxia
Flat affect

Rationale
Catatonia is the term to describe stupor, rigidity, or extreme flexibility of the limbs;
excitability; confusion; and lack of verbal expression. Alogia is a term used to describe
an inability to speak or near-absence of speech. Echopraxia is the term for the
mimicking or repetition of the actions of another person. Flat affect is the term for
blunted or constricted facial expression.

STUDY TIP: Study goals should set out exactly what you want to accomplish. Do not
simply say, 'I will study for the exam.' Specify how many hours, what day and time, and
what material you will cover.

Which client behavior would indicate to the nurse that a client with
schizophrenia is improving and that the client’s plan of care can be
updated?
Avoids other clients
Expresses negative feelings freely

Describes delusions in meticulous detail

Communicates with others in an organized manner

Rationale
Communicating with others in an organized manner indicates a client with
schizophrenia is improving. The presence of loosely associated tangential thinking is
one of the cardinal symptoms of schizophrenia; its lessening will demonstrate
improvement. Avoiding other clients may reflect a withdrawal from reality and does
not necessarily signal improvement. Most clients with schizophrenia are able to
express negative feelings freely, because control by the ego is ineffective. Describing
delusions in detail does not demonstrate improvement; paranoid delusions are usually
well organized and, on the surface, often seem logical.

Test-Taking Tip: Get a good night’s sleep before an exam. Staying up all night to study
before an exam rarely helps anyone. It usually interferes with the ability to concentrate.

The nurse administers an antipsychotic medication to a client. The

nurse will assess the client for which common, manageable side effect?
Jaundice
Melanocytosis
Drooping eyelids

Unintentional tremor

Rationale
Unintentional tremor is one of the extrapyramidal side effects of antipsychotic
medications; it is considered common and manageable. Jaundice is a severe
occurrence but not a common one; periodic liver function tests should be performed.
An excessive number of melanocytes is not a side effect of antipsychotics. Drooping of
the eyelids is not a common side effect.

Laboratory reports reveal that the client’s thyroxine levels are low. Which
medication might have led to this condition?
Lithium
Fluoxetine

Risperidone
Carbamazepine
Rationale
Lithium is used to treat bipolar disorder. Decreased levels of thyroxine and
triiodothyronine may indicate hypothyroidism. Lithium may cause a goiter, which is
associated with hypothyroidism. Fluoxetine is a serotonin reuptake inhibitor that may
lead to hyponatremia. Risperidone is a second generation antipsychotic used to treat
bipolar disorder that does not cause hypothyroidism. Carbamazepine is an
antiepileptic medication used to treat bipolar disorder; this medication may cause
leukopenia, anemia, and thrombocytopenia.

Test-Taking Tip: Identifying content and what is being asked about that content is
critical to your choosing the correct response. Be alert for words in the stem of the
item that are the same or similar in nature to those in one or two of the options .

A client comes to the mental health clinic for a monthly injection of 37.5
mg of fluphenazine decanoate. It is available as 25 mg/mL. How many

milliliters of solution would the nurse administer? Record your answer

to one decimal place. 1.5

mL

Rationale
Use the 'desire over have' formula of ratio and proportion. In this case, 37.5 mg divided
by 25 mg/mL = 1.5 mL. 

The health care provider instructs a client who has been taking clozapine
for 2 months to discontinue the medication for a few weeks. Which
laboratory parameter would the nurse recognize as supporting the
intervention?
Hemoglobin of 12 g/dL

Platelet count of 30,000/mm 3

3
 White blood cell count of 2,500/mm 3
Red blood cell count of 4.2 million/mm 3

Rationale
Because clozapine may cause agranulocytosis, the client’s white blood cell (WBC) count
should be monitored weekly. The medication should be discontinued if the count falls
below 3,000/mm 3. Thus the medication should be discontinued when the WBC count
is 2,500/mm 3. A platelet count of 30,000/mm 3may indicate thrombocytopenia.
Clozapine may not cause thrombocytopenia. A hemoglobin of 12 g/dL is within normal
range. A red blood cell count of 4.2 million/mm 3 is a normal value.

Which therapeutic communication technique is demonstrated when the

nurse says, 'I'm confused about exactly what is upsetting you. Would you
go over that again, please?'
Clarifying
Structuring
Confronting

Paraphrasing

Rationale
The nurse is asking for clarification to better understand the intended message.
Structuring creates order and allows a client to become aware of problems.
Confronting is used when there are discrepancies between what a person says and
what a person does or between verbal and nonverbal messages. Paraphrasing helps the
speaker and listener understand how the information is being interpreted.

Which response is best to give a client who has schizophrenia, when he

interjects random and nonsensical sentences that have nothing to do
with the main conversational topics?
'You aren't making any sense; let's talk about something else.'
'Why don't you take a rest? We can talk again later this afternoon.'
'I'd like to understand what you're saying, but you're too confused now.'

'I'd like to understand what you're saying, but I'm having trouble following
you.'

Rationale
When the nurse conveys a desire to understand, this increases the client's feeling of
self-esteem. Nurse also states reality and the reality is that as a listener, the
conversation is hard to follow, and the intended meaning is not being received. Clients
with schizophrenia have problems with associative links, and these same problems will
occur regardless of the topic. The other responses serve to block or stop
communication, and they suggest that the nurse doesn’t want to speak to the client
unless he makes sense.

Which problem is common for clients with the diagnosis of

schizophrenia?
Change in mental status
Disordered thinking

Rigid personal boundaries

Violence directed toward others

Rationale
The schizophrenic individual has neurobiological changes that cause disorders in
thought process and perceiving reality. Change in mental status is not expected, but
the client’s baseline behaviors must be identified and communicated to all caregivers.
Illogical thinking and impaired judgment are associated with schizophrenia.
Individuals with the diagnosis of schizophrenia often have personal boundary
difficulties. They lack a sense of where their bodies end in relation to where others
begin. Loss of ego boundaries can result in depersonalization and derealization. Most
clients with schizophrenic disorders are not violent.

Which clinical finding is observed in catatonic schizophrenia?

Crying

Self-mutilation
Immobile posturing
Repetitive rituals

Rationale
Clients with catatonia exhibit rigidity and posturing behaviors. Most clients with
catatonic schizophrenia are unable to express feelings. Self-mutilation is associated
with borderline personality disorder. Repetitive rituals are associated with obsessive-
compulsive disorders.

Which statement indicates that the client is experiencing auditory

hallucinations?
'Get these horrible snakes out of my room!'

'I am not the devil! Stop calling me names!'

'The food on this plate has poison in it.'
'I saw an alien spaceship and now I feel sick.'

Rationale
The client is responding to messages that she or he is hearing, which are auditory
hallucinations. The responses regarding the snakes and the spaceship are examples of
visual hallucinations because they describe what the client sees. The accusation of
poisoning is the statement of a client who is suspicious and paranoid but not
hallucinating.

Which behaviors are commonly exhibited by clients who are diagnosed

with schizophrenia?
Disorientation, forgetfulness, and anxiety
Grandiosity, arrogance, and distractibility

Withdrawal, regressed behavior, and lack of social skills

Slumped posture, pessimism, and cognitive retardation

Rationale
Withdrawal, regressed behavior, and lack of social skills are classic behaviors exhibited
by clients with a diagnosis of schizophrenia. Disorientation, forgetfulness, and anxiety
are more commonly associated with dementia. Grandiosity, arrogance, and
distractibility are more commonly associated with bipolar disorder, manic phase.
Slumped posture, pessimism, and cognitive retardation are more commonly
associated with depression.

A client who has schizophrenia sees a group of visitors sitting together

and says, 'I know they’re talking about me.' Which altered thought
process is the client demonstrating?
Flight of ideas
Ideas of reference

Grandiose delusion
Thought broadcasting
Rationale
In ideas of reference, the client has a delusional belief that she or he is the focus of
ordinary events. Flight of ideas is the rapid thinking and speaking seen in clients in a
manic state. Grandiose delusions are irrational beliefs that overestimate one’s ability or
worth. Thought broadcasting is the delusional belief that others can read one’s
thoughts.

For a young client with the diagnosis of schizophrenia, when do

difficulties with reality testing usually start?
Early childhood
Late childhood

Puberty
Adolescence

Rationale
The usual age of onset of schizophrenia is adolescence or early adulthood. Signs and
symptoms usually do not appear earlier in life.

A client with schizophrenia is apathetic and exhibits an inappropriate

affect. Which behavior is the client likely to exhibit?
Logical deductions
Suicidal preoccupation

Absence of self-criticism
Response to internal stimulation

Rationale
Clients with schizophrenia have increased levels of dopamine, which produces
hallucinations. The most common are auditory hallucinations, causing the client to
respond to internal stimulation. The loosening of associative links that occurs in
schizophrenia makes logical deductions impossible. Clients with schizophrenia do
commit suicide, but thought disorders limit the client’s ability to organize and
articulate a coherent suicide plan. Clients with schizophrenia have low self-esteem and
usually have feelings of guilt, self-blame, and self-criticism.

Test-Taking Tip: Be aware that information from previously asked questions may help
you respond to other examination questions.

Which initial approach would the nurse take for a client with
schizophrenia?
Discuss important life events.
Provide a nonthreatening environment.
Concentrate on the content of delusions.

Limit topics for discussion to recent situations.

Rationale
The nurse would provide a nonthreatening environment. These clients are
hypersensitive to external stimuli and respond with less anxiety to a minimally
threatening environment. Discussing important life events is too threatening an
approach and interferes with the goals of therapy. Focusing on delusional material will
reinforce the delusional system. Limiting topics for discussion to recent situations is
not therapeutic; it may trigger suspiciousness and hostile outbursts.

Which therapeutic intervention would be included in the plan of care for

a confused, delusional client?
Minimize stimuli by maintaining a quiet, darkened environment.
Encourage realistic activity based on the client’s ability.
 Focus frequently on the content of the delusions.

Perform physical hygiene even if the client is capable.

Rationale
The nurse would encourage realistic activity based on the client’s ability. These clients
need sensory stimulation to maintain orientation and should be encouraged to do as
much as possible for themselves, depending on their ability. Surroundings should be
bright (not darkened) to minimize confusion. Although the client is having delusions,
the nurse would not focus frequently on the content of the delusions. This intervention
reinforces those delusions. Although it is important to ensure that the client receives
physical hygiene and comfort, the client should be encouraged to do as much as
possible.

Which response would the nurse make to a client with schizophrenia

who is going to occupational therapy for the first time and does not
want to go?
'It’s only for an hour, and then you’ll be back.'
'Try it once. If you don’t like it, you don’t have to go back.'

'Tell me what concerns you about going to occupational therapy.'

'Your primary health care provider prescribed it as part of your treatment. You
should go.'

Rationale
'Tell me what concerns you about going to occupational therapy,' is an open-ended
statement that allows the nurse to explore the client’s concerns. If the client would feel
more comfortable having the nurse go with the client to the first session, this idea may
be explored next. The statement, 'It’s only for an hour, and then you’ll be back,' will do
nothing to allay the client’s anxiety about facing a new situation. Telling the client to
try it once and that the client does not have to go back is not true; even if the client
does not like the therapy, the client should be encouraged to go as part of the overall
therapy program. Telling the client that the primary health care provider has,
'...prescribed the therapy as part of the treatment...' and that the client should go will
do nothing to allay the client’s anxiety about facing a new situation.

Which response would the nurse make during the admission procedure
for a client who cries out at intervals, 'No, no! I didn’t kill him! You know
the truth—tell that police officer! Please help me'?
Listening attentively and assuming an expression of disbelief

Saying, 'I want to help you. I realize that you must be very frightened.'
Sitting quietly and refraining from responding to the client’s statements
Replying, 'Don’t be so upset. No one is talking to you; those voices are part of
your illness.'

Rationale
The nurse would say, 'I want to help you. I realize that you must be very frightened.'
Telling the client that help is available demonstrates an understanding of the client’s
feelings and encourages the client to share feelings, which is an immediate need.
Assuming an expression of disbelief is judgmental and demeaning to the client. Sitting
quietly and not responding to the client’s statements will probably intensify the client’s
fears and anxiety. Although telling the client not to be upset because no one is talking
points out reality, it also gives a command ('Don’t be so upset') that is unrealistic and
closes the communication process.

Which approach would the nurse use for a client who describes
delusions in minute detail?
Changing the topic to reality-based events

Continuing to discuss the delusion with the client

Getting the client involved in a social project with peers
 Disputing the perceptions with the use of logical thinking

Rationale
The nurse would change the topic to reality-based events. Decreasing time spent on
delusions prevents reinforcement of psychotic thinking. Discussing reality-based
events improves contact with reality. Encouraging discussion will give validity to the
delusion. The client will have difficulty getting involved in a social activity with peers;
this activity will not stop the delusion and may make the situation worse. Challenging
the client by disputing the perceptions will increase anxiety.

At which time would the nurse expect the hallucinations to be more

frequent in a client with schizophrenia?
Resting
Playing sports

Watching television
Interacting with others

Rationale
The nurse would expect the hallucinations to increase when resting. Hallucinations
occur most often when sensory stimulation is diminished because there is less
competition for attention. Playing sports, television-watching, and interacting with
others compete for sensory attention, thereby diminishing hallucinations.

Test-Taking Tip: Stay away from other nervous students before the test. Stop reviewing
at least 30 minutes before the test. Take a walk, go to the library and read a magazine,
listen to music, or do something else that is relaxing. Go to the test room a few
minutes before class time so that you are not rushed in settling down in your seat.
Tune out what others are saying. Crowd tension is contagious, so stay away from it.
When a disturbed client says, 'My lacket huss kelong mon,' which
response would the nurse make?
Try to learn the language of the client.

Tell the client that these words cannot be understood.

Communicate in simple terms directed toward the client.
Recognize that the client needs a nurse who can understand the fantasies
expressed.

Rationale
Telling the client that these words are not understood is a simple statement that
provides feedback and points out reality. Neologisms ('My lacket huss kelong mon')
have symbolic meaning only for the client, and the nurse would not try to learn the
language because it promotes ineffective coping. Although communicating in simple
terms should be done, it does not address the problem of the client using neologisms.
No one other than the client can understand the fantasies, so finding a nurse to
understand the fantasies is nontherapeutic and ineffective.

The nurse is administering a prescribed antidepressant medication to a

client in an inpatient mental health facility. Which action would the
nurse perform to ensure the client is not stashing doses of medication?
Provide a 1:1 sitter for the client.
Observe the client swallowing the medication.
Ask a client’s family member to ensure the dose is taken.

Set the correct medication dose on the client’s meal tray.

Rationale
Clients in inpatient mental health facilities may attempt to stash doses of prescribed
medication for use in a suicide attempt. The nurse will need to watch the client to
ensure the medication is swallowed and not 'cheeked.' It is the nurse’s responsibility to
oversee medication administration, not a sitter or family member. A client will never be
left to take medication unsupervised; therefore, the nurse would not leave the dose in
a client’s room or on a meal tray.

Which nursing action has the highestpriority for a client with delirium?
Maintaining skin integrity

Planning for behavioral interventions

Creating a calm and safe environment
Maintaining personal contact through touch

Rationale
The nurse caring for a client with delirium should ensure client safety and ensure a
calm and safe environment. The nurse should encourage family members to stay at
the bedside along with the client or move the client to the nurses’ station to guarantee
safety. The client is at a risk for skin breakdown, which is of medium priority. The nurse
should ensure the safe environment first, then when it is possible, plan for client-
specific behavioral interventions. Reorientation is then followed by contacting the
client personally through touching and verbal communication.

On a behavioral health inpatient unit, the nursing student cares for a

client who began anxiolytic medications less than 24 hours ago. Which
statement made by the nursing student indicates the need for further
teaching regarding administration of anxiolytic medications on a
behavioral health unit?
'I should monitor vital signs of the client.'
'I will check the client’s oral cavity for cheeking of medications.'
 'I will compare my assessment of the client with the client’s baseline
assessment.'

'I will encourage the client to attend aerobic exercise classes.'

Rationale
The nurse would encourage the client to change positions slowly to minimize dizziness
and falls; therefore aerobic exercises are not appropriate until the client has adjusted to
the medication. The nurse would frequently monitor the client’s vital signs. The nurse
would check the client’s oral cavity for hoarding or cheeking of medications. The nurse
would compare current assessments with baseline assessments to determine if status
is improving.

The nurse observed seizures in a client who is taking lithium for cycles
of mania. Which laboratory parameters may lead to this condition?
1 mEq/L (1 mmol/L) serum lithium levels
3 mEq/L (3 mmol/L) serum lithium levels
135 mEq/L (135 mmol/L) serum sodium levels

140 mEq/L (140 mmol/L) serum sodium levels

Rationale
Serum lithium levels exceeding 2.5 mEq/L (2.5 mmol/L) may cause seizures,
gastrointestinal discomfort, tremors, confusion, and somnolence. A serum lithium
level of 3 mEq/L (3 mmol/L) serum may lead to seizures. The desired long-term serum
lithium level is 1 mEq/L (1 mmol/L). The normal range of serum sodium levels is from
135 to 145 mEq/L (135–145 mmol/L).

The nurse observes aggressive behaviors and suicidal ideations from a

client taking medications for cystic acne. Which medication may be
responsible for the client’s condition?
Celecoxib
Isotretinoin
Minocycline

Meclofenamate

Rationale
Isotretinoin a potent and effective oral agent that is used to treat severe cystic acne
when other treatments do not respond. It causes many multiple side effects that
include aggressive behaviors and suicidal ideations. Minocycline is a systemic
antibiotic that is more expensive and causes fewer gastrointestinal side effects.
Celecoxib and meclofenamate are nonsteroidal anti-inflammatory agents that cause
nausea, vomiting, and indigestion as side effects.

The nurse is reviewing the data of four clients with psychologic

disorders. Which client would require monitoring of serum sodium
levels based on the given data?

Client A
Client B

Client C
Client D

Rationale
A client taking lithium requires serum sodium level monitoring because both sodium
and lithium are monovalent positive ions, and one can affect the other. Client D
requires monitoring of serum sodium levels. Client A may require respiratory
monitoring if he or she has a history of hepatic dysfunction because diazepam may
cause respiratory depression. Client B may not require monitoring of serum sodium
levels. Client C who is taking clozapine may require monitoring of his or her white
blood cell count to check for symptoms of agranulocytosis.

A client with schizophrenia is prescribed chlorpromazine. The nurse

instructs the family on extrapyramidal side effects of the medication.
The nurse concludes teaching was effective when the family identifies
which as a late extrapyramidal side effect?
Tremors

Restless movements
Muscle spasms of neck
Worm-like tongue movements

Rationale
Chlorpromazine is a first-generation antipsychotic medication that may cause
extrapyramidal side effects. Late extrapyramidal side effects include fine, worm-like
tongue movements. Tremors, restless movements, and muscle spasms of the neck,
back, tongue, or face are early extrapyramidal side effects.

While assessing a client with schizophrenia who is receiving

chlorpromazine, the nurse finds lead pipe rigidity, sudden high fever,
and sweating. Which medications would the nurse anticipate being used
to treat these adverse effects? Select all that apply. One, some, or all
responses may be correct.
Loxapine
Dantrolene
 Thiothixene
Haloperidol
Bromocriptine

Rationale
Lead pipe rigidity, sudden high fever, and sweating are symptoms of neuroleptic
malignant syndrome; this condition is an adverse effect of chlorpromazine.
Medications used to treat this syndrome are dantrolene and bromocriptine. Loxapine,
thiothixene, and haloperidol are first-generation antipsychotics that should not be
prescribed because they may lead to severe complications.

Test-Taking Tip: Be alert for details about what you are being asked to do. In this
question type, you are asked to select all options that apply to a given situation or
client. All options likely relate to the situation, but only some of the options may relate
directly to the situation.

The nurse is developing a teaching plan for a client prescribed

monoamine oxidase inhibitors (MAOIs). Which food would the nurse
instruct the client to avoid while receiving treatment?
Bologna
Potatoes

Citrus fruit
Grapefruit juice

Rationale
Bologna has a high tyramine content; tyramine should not be consumed by clients
taking MAOIs because the medication interaction may cause severe hypertension.
Potatoes and citrus fruits do not contain tyramine. Grapefruit juice may cause a
negative medication interaction in clients taking buspirone.

Which intervention would the nurse use for a client with schizophrenia
who is experiencing hallucinations?
Advocate for client’s admission to institutional care.
Acknowledge that the client’s experience is real for him.
Prepare the client for electroconvulsive therapy.

Advise the family to act normally around the client.

Rationale
The nurse accepts the client and the client's fears to facilitate effective communication.
Today mental health therapy is directed toward returning the client to the community
as rapidly as possible. Electroconvulsive therapy is not the treatment of choice for
clients with schizophrenia. Family’s behavior and interaction with the client should be
assessed first. Based on that assessment, the nurse may decide to teach the family how
to respond when the client is actively hallucinating.

Which defense mechanism is most commonly used by clients who are

diagnosed with schizophrenia, undifferentiated type?
Projection
Repression
Regression

Conversion

Rationale
Regression, an unconscious defense mechanism that reduces anxiety by returning to
behavior that was successful in earlier years, is commonly used by clients with
undifferentiated schizophrenia to reduce anxiety. Regression is considered a relatively
primitive defense mechanism that leads to disorganized thought processes. Projection
is the attributing of unacceptable feelings or thoughts to others. It is an organized
defense used by clients with paranoid, not undifferentiated, schizophrenia. For clients
with undifferentiated schizophrenia, disorganized thought processes prevent use of
projection. Clients with schizophrenia are not able to use repression (putting
disturbing thoughts, feelings, or desires out of the conscious mind). Conversion (an
unconscious defense mechanism in which a person develops physical symptoms that
have no organic cause) is usually not used by clients with undifferentiated
schizophrenia.

For a client with schizophrenia, which symptoms are classified as

negative symptoms? Select all that apply. One, some, or all responses
may be correct.
Lack of energy
Anhedonia
Illogical speech

Ideas of reference
Agitated behavior

Rationale
A lack of energy (anergy) and anhedonia (inability to experience pleasure) are negative
symptoms associated with schizophrenia. Illogical speech and ideas of reference, (i.e., a
person believes she or he is the object of environmental attention) are positive
symptoms of schizophrenia. Agitated, hostile, angry, and violent behaviors are positive
symptoms of schizophrenia.

As the nurse approaches a client who has schizophrenia, he

unexpectedly shouts, 'Get out of here before I hit you! Go away!' Which
rationale best explains the client’s behavior?
Hallucinations cause aggression.

He feels threatened by the nurse.

He is afraid of harming the nurse.
The nurse is a phobic object.

Rationale
Clients acutely ill with schizophrenia frequently do not trust others; fear and feeling
threatened can cause them to lash out. Hallucinations can cause fear and anxiety, and
a client’s act of self-protection could appear aggressive, but an experienced nurse will
intervene before the hallucinations produce high levels of anxiety. Clients acutely ill
with schizophrenia usually are more concerned with what is happening to them and
are not able to be concerned about others. The nurse could be a phobic object, but if
so, the client’s fear reaction should be anticipated and nursing action should be
adjusted accordingly (e.g., ask for permission to approach).

The client says, 'Those foreign agents implanted a microcomputer in my

ear.' Which psychotic symptom is the client experiencing?
Illusions

Delusion
Hallucination
Disorganized thoughts

Rationale
The client is expressing a delusion, which is a fixed set of false beliefs that cannot be
corrected by reason. An illusion is a misperception of an actual environmental
stimulus. Disorganized thought would include the inability to organize thought
processes. Hallucinations are false sensory stimuli (e.g., hearing voices, seeing dead
people).

For clients who have severe psychiatric disorders, which therapeutic

outcome is anticipated for the majority of prescribed antipsychotic
medications?
Improvement of judgment and cognition

Improvement of verbal and social skills

Elimination of neurotic signs and symptoms
Management of hallucinations and delusions

Rationale
Antipsychotics are a class of medications primarily used to manage the positive signs
and symptoms associated with psychoses, including hallucinations, delusions,
paranoia, and disorganized speech. (Some of the newer antipsychotics may help with
the negative symptoms, such as flat affect and avolition.) Improved judgment and
social skills may be outcomes related to managing the psychoses. These medications
are used to minimize psychotic, not neurotic, signs and symptoms.

Which response is best to give to a client who states, 'The voices are
saying I killed my husband'?
'You're having very frightening thoughts right now.'

'We'll put you in a private room where you'll be safe.'

'Tell me more about these worries about your husband.'
'I just saw your husband, and he seems to be doing fine.'
Rationale
The nurse demonstrates awareness of the client's feelings (frightening thoughts); this
opens the channel of communication. A private room is isolating, and this will worsen
the hallucinations. Focusing on delusional content (tell me about) reinforces false
beliefs. The nurse cannot talk the client out of these delusions by pointing out reality
(he’s doing fine).

Which description would the nurse use to describe a client with

schizophrenia who tells the nurse, 'My heart has stopped and my veins
have turned to glass'?
Echolalia

Hypochondriasis
Somatic delusion
Agnosia

Rationale
The client is experiencing a somatic delusion. A somatic delusion is a fixed false belief
about one’s body. Echolalia is the automatic and meaningless repetition of another’s
words or phrases. Hypochondriasis is a severe, morbid preoccupation with an
unrealistic interpretation of real or imagined physical symptoms. Agnosia is the loss of
sensory ability to recognize objects.

Test-Taking Tip: After you have eliminated one or more choices, you may discover that
two of the options are very similar. This can be very helpful, because it may mean that
one of these look-alike answers is the best choice and the other is a very good
distractor. Test both of these options against the stem. Ask yourself which one
completes the incomplete statement grammatically and which one answers the
question more fully and completely. The option that best completes or answers the
stem is the one you should choose. Here, too, pause for a few seconds, give your brain
time to reflect, and recall may occur.
Which response would the nurse make to a client with schizophrenia
who tells the nurse, 'Everyone hates me'?
'Tell me more about this.'
'Everyone does not hate you.'

'That feeling is part of your illness.'

'You may be promoting this feeling yourself.'

Rationale
The response, 'Tell me more about this,' explores more fully the client’s ideas,
experiences, or relationships; this response promotes communication. Saying,
'Everyone does not hate you,' is arguing about delusions, which increases anxiety and
diminishes trust and may lead the client to defend the delusion. The response, 'That
feeling is part of your illness,' denies the client’s feelings and implies that the client is
wrong; it may cause the client to defend the delusion further. The response, 'You may
be promoting this feeling yourself,' puts the blame on the client and implies that the
feelings are based on reality.

Which statement from the client would alert the nurse the client is
experiencing a hallucination?
'I am going to save the world because I am God.'

'My insides smell like they’re going to just rot away.'

'Unless I gamble at least once a week, I feel extremely anxious.'
'It’s crazy, but I keep thinking that something terrible will happen to my baby.'

Rationale
The statement, 'My insides smell like they’re going to just rot away,' is an example of
an olfactory hallucination, a sense of perception for which no external stimulus exists.
The statement, 'I am going to save the world because I am God,' is an example of a
delusion of grandeur. A delusion is a fixed false belief held to be true by the person
even in the presence of evidence to the contrary. The statement, 'Unless I gamble at
least once a week, I feel extremely anxious,' is an example of a compulsion. A
compulsion is a repetitive, intrusive urge to perform an act contrary to one’s ordinary
wishes or standards. The response, 'It’s crazy, but I keep thinking that something
terrible will happen to my baby,' is an example of an obsession. An obsession is an
insistent, painful, intrusive idea, impulse, or emotion that arises from within and
cannot be suppressed or ignored.

Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least
one of them will be clearly wrong. Eliminate this one from consideration. Now you
have reduced the number of response choices by one and improved the odds.
Continue to analyze the options. If you can eliminate one more choice in a four-option
question, you have reduced the odds to 50/50. While you are eliminating the wrong
choices, recall often occurs. One of the options may serve as a trigger that causes you
to remember what a few seconds ago had seemed completely forgotten.

Which response would the nurse make to a client with schizophrenia

who says, 'I’m starting to hear voices'?
'How do you feel about the voices, and what do they mean to you?'

'You’re the only one hearing the voices. Are you sure you hear them?'
'The health team members will observe your behavior. We won’t leave you
alone.'

'I understand that you’re hearing voices talking to you and that the voices are
very real to you. What are the voices saying to you?'

Rationale
The nurse would say, 'I understand that you’re hearing voices talking to you and that
the voices are very real to you. What are the voices saying to you?' Acknowledging that
the client is hearing voices and that the voices are very real to the client validates the
presence of the client’s hallucinations without agreeing with them, which
communicates acceptance and can form a foundation for trust; it may help the client
return to reality. The nurse also needs to assess the content of the voices to determine
the risk of self-injury or violence against others. The client’s contact with reality is too
tenuous to explore what the voices mean. Thus, the nurse would not ask, 'How do you
feel about the voices, and what do they mean to you?' Saying that the client is the only
one hearing the voices and asking whether the client is sure the voices are being heard
demeans the client, which blocks the development of a trusting relationship and future
communication. Telling the client that the health team members will observe the
behavior and that the client won’t be left alone is focusing the response on the health
care team rather than the client.

Which response would the nurse make to a disturbed client who says,
'The voices are saying that I killed my husband'?
'I just saw your husband, and he’s doing fine.'

'Tell me more about your concerns for your husband.'

'We’ll put you in a private room where you’ll be safe.'
'You seem to be having very frightening thoughts right now.'

Rationale
'You seem to be having very frightening thoughts right now,' demonstrates that the
nurse understands the client’s feelings; reflection opens a channel for communication.
The nurse cannot talk the client out of delusions by pointing out reality by saying, 'I
just saw your husband, and he’s doing fine.' Focusing on delusional content only
reinforces false beliefs. 'Tell me more about your concerns for your husband,' focuses
on the delusions rather than on the feelings the client is experiencing. 'We’ll put you in
a private room where you’ll be safe,' does not reflect the content of the client’s
statement; in addition, it is punitive and illegal.

Which phenomenon would the client be experiencing when the client

looked at a linen sheet on a clothesline and thought it was a ghost?
An illusion
A delusion
A hallucination

A confabulation

Rationale
When the client thinks a linen sheet on the clothesline is a ghost, this is an example of
an illusion. An illusion is a misinterpretation of an actual sensory stimulus. A delusion
is a false, fixed belief. A hallucination is a false sensory perception that occurs with no
stimulus. Confabulation is a filling in of blanks in memory.

Which response would the nurse make to a client who says, 'I used to
believe that I was God, but now I know that that’s not true'?
'You really believed that?'
'Many people have this delusion.'

'This is a sign you are getting better.'

'What caused you to think you were God?'

Rationale
The nurse would say, 'This is a sign you are getting better.' This response supports
reality and self-awareness while helping the client look to the future rather than focus
on the past. The response, 'You really believed that?' may be taken as ridicule of the
client, and it focuses on the past. The response, 'Many people have this delusion,' is a
false statement, and the statement dismisses an opportunity to validate how the client
feels now. Why the client had this delusion is unimportant at the moment; the
response, 'What caused you to think you were God?' focuses on the past.

STUDY TIP: Record the information you find to be most difficult to remember on 3' ×
5' cards and carry them with you in your pocket or purse. When you are waiting in
traffic or for an appointment, just pull out the cards and review again. This 'found' time
may add points to your test scores that you have lost in the past.

A client is heard saying, 'I like eggs, fried by Meg, served on a keg,
kicked in the leg, and don’t want her to hoopanize them ever again.'
Which documentation entry would the nurse use to record this finding?
'Demonstrating word salad and echolalia speech patterns.'
'Exhibiting clang association and neologism speech patterns.'
'Speech appears to be nonsensical and sing-song in tempo.'

'Speech has deteriorated to incoherent jabbering with loose associations.'

Rationale
The nurse would chart: 'Exhibiting clang association and neologism speech patterns.'
Clang association is the choice of words based on their sound rather than their
meaning; often in this condition the words rhyme (e.g., eggs, Meg, keg, leg).
Neologisms are made-up words that have meaning for only the client (e.g.,
hoopanize). Word salad is a jumble of meaningless words and echolalia is the
repeating of another’s words. The client did neither of these speech patterns. The term
nonsensical is not objective and would not be used. Although loose associations are
objective, jabbering is subjective and provides little concrete information regarding the
client’s speech patterns.

STUDY TIP: Record the information you find to be most difficult to remember on 3' ×
5' cards and carry them with you in your pocket or purse. When you are waiting in
traffic or for an appointment, just pull out the cards and review again. This 'found' time
may add points to your test scores that you have lost in the past.
Which response would the nurse make to a client who says, 'They’re
saying terrible things about me. Can’t you hear them'?
'It seems you’ve heard them before.'
'Try to get control of your feelings.'

'There’s no one here but me.'

'I don’t hear anyone else talking, but I can see that you’re upset.'

Rationale
Responding 'I don’t hear anyone else talking, but I can see that you’re upset' interjects
reality and focuses on the client’s feelings. Saying 'It seems you’ve heard them before'
elicits a yes-or-no answer and does not foster communication. 'Try to get control of
your feelings' is a directive response that will be perceived as threatening to a
disturbed client experiencing hallucinations. Although this interjects reality ('There’s no
one here but me.'), it needs to address the client’s feelings.

Which initial approach would the nurse use to address a client with
schizophrenia who is beginning to pace around the lounge while glaring
at other clients?
Pointing out the behavior to the client
Walking with the client to a quiet area on the unit
Suggesting that the client go to the gym to work out

Arranging for an additional staff member to be present in the vicinity of the

client

Rationale
The nurse would walk with the client to a quiet area on the unit. The client is
demonstrating signs of agitation, and stimuli from the environment must be reduced.
Pointing out the behavior is confrontational and may increase the client’s agitation.
The client would not be left unattended at this time; aggressive physical activity at this
time may increase the agitation. Arranging for the presence of another staff member
will not interrupt the client’s behavior, which is the priority at this time.

Which approach would the nurse use for a delusional male client who
has increasing pacing and agitation and verbalizes the belief that others
are out to cause him harm?
Advising the client to use a punching bag
Moving the client to a quiet place on the unit
Encouraging the client to sit down for a while

Allowing the client to continue pacing with supervision

Rationale
The nurse would move the client to a quiet place on the unit. A client losing control
feels frightened and threatened; this client needs external controls and a reduction in
external stimuli. Advising the client to use a punching bag is helpful if the client is
holding back aggressive behavior but is not useful in easing agitation associated with
delusions. The client is unable, at this time, to sit in one place; the agitation is building
and this would escalate the situation. Because the pacing is increasing and the client
believes others are out to harm him, continuing with the pacing keeps the client
around others, which will increase anxiety and may in turn cause the pacing to get
completely out of control.

Test-Taking Tip: If the question asks for an immediate action or response, all of the
answers may be correct, so base your selection on identified priorities for action.

Which response would the nurse make to a client who has been on a
psychiatric unit for several weeks and continually talks about delusional
topics?
 Asking the client to explain the delusion
Allowing the client to maintain the delusion

Encouraging the client to focus on reality issues

Explaining to the client why the thoughts are not true

Rationale
Because the client has been on the unit for several weeks, the nurse would encourage
the client to focus on reality issues. Discussing reality-based issues helps decrease
delusional and hallucinatory activity by reducing feelings of isolation and competition
for sensory awareness. Asking the client to explain the delusions or allowing the client
to maintain them will support and reinforce the delusions and validate them, which
will hinder the client’s progress. Explaining why the delusions are not true is a
judgmental response that may decrease the client’s trust, increase anxiety, and cause
the client to justify the delusions to the nurse.

Which response would the nurse make to a client who says, 'Please let
me go. I trust you. The Mafia is going to kill me tonight'?
'You’re frightened. Come with me to your room, and we can talk about it.'

'Come with me to your room. I’ll lock the door and no one will get in to harm
you.'

'Nobody here wants to harm you, and you know that. I’ll come with you to
your room.'
'Thank you for trusting me. Maybe you can trust me when I tell you that no
one will kill you here.'

Rationale
The nurse would say, 'You’re frightened. Come with me to your room, and we can talk
about it.' Acknowledging that the client is frightened and offering a chance to talk
acknowledges the client’s feelings and provides assurance that the staff member will be
present. Locking the client in a room will only increase the fear and worsen the
delusion, and it is illegal. The client does not know that no one wants to cause the
client harm; otherwise, the delusion would not be present. Also, saying, 'you know that'
is accusatory. The client is not ready to accept that no one wants to kill the client and
really believes that danger is imminent. Thus saying 'no one will kill you here' is
ineffective.

Which response would the nurse say to a client with schizophrenia who
continues to say, 'They’re trying to kill me. They all are'?
'We’re here to protect you.'

'No one wants to hurt anyone.'

'You’re having very frightening thoughts.'
'Tell me more about their wanting to kill you.'

Rationale
The nurse would say, 'You’re having very frightening thoughts.' The observation that
the client is experiencing frightening thoughts is a reflection of the client’s feelings; it
leaves the line of communication open. Telling the client that the staff is there to
protect the client does not provide security, because the client may believe that the
nurse is one of the people plotting. Telling the client that no one wants to hurt anyone
discounts the client’s thoughts and may increase the agitation. Asking the client to
detail the plot supports the client’s delusion.

Which response would the nurse make to a client who tells the nurse, 'A
man is speaking to me from the corner of the room. Can you hear him?'
'What’s he saying to you? Does it make any sense?'
'Yes, I hear him, but I can’t understand what he’s saying.'
'I don’t hear him. There’s no one in the corner of the room.'
 'No, I don’t hear him, but is it making you uncomfortable to hear him?'

Rationale
The statement 'No, I don’t hear him, but is it making you uncomfortable to hear him?'
points out reality, identifies potential feelings, and prevents the nurse from supporting
the hallucination. Asking what the man is saying to the client and whether it makes
any sense is nontherapeutic because it supports and focuses on the hallucination. 'Yes,
I hear him, but I can’t understand what he is saying' is nontherapeutic because it
supports and focuses on the hallucination; also, it is not truthful. Although denying
hearing the voice and pointing out that there is no one else in the room points out
reality, this statement does not focus on the client’s feelings.

During admission the pregnant client shouts, 'My stomach is filled with
bombs, and I’ll blow up this place if anyone comes near me.' Which
thought disorder would the nurse conclude the client is exhibiting?
Ideas of reference
Loose associations
Delusional thinking
Tactile hallucinations

Rationale
The client is experiencing delusional thinking. Delusions are false fixed beliefs that
have a minimal basis in reality. This is a somatic delusion. Ideas of reference
(referential) are false beliefs that every statement or action of others relates to the
individual. Loose associations are verbalizations that sound disjointed to the listener.
Tactile hallucinations are false sensory perceptions of touch without external stimuli.

A client on the psychiatric unit says, 'I’m a movie star, and the other
clients are my audience.' Which thought process would the nurse
document the client is experiencing?
Flight of ideas
Referential delusions
Delusions of grandeur
Auditory hallucination

Rationale
The nurse would document the client is having delusions of grandeur. A delusion of
grandeur is a fixed false belief that the person is a powerful, important person. Flight
of ideas is an increase in the speed of thinking causing the person to shift from one
idea to another without completing the previous idea; it is often expressed with
pressured speech. A referential delusion is an incorrect interpretation of an external
event as having special meaning to the client. An auditory hallucination is experienced
when a person hears voices without external stimuli.

STUDY TIP: Enhance your time-management abilities by designing a study program

that best suits your needs and current daily routines by considering issues such as the
following: (1) amount of time needed; (2) amount of time available; (3) 'best' time to
study; (4) time for emergencies and relaxation.

Which activity would the nurse suggest for a withdrawn client who is
hallucinating?
Going for a walk with the nurse
Watching a movie with other clients
Joining a board game with a group of clients
Playing a game of cards alone in the dayroom
Rationale
Walking with the nurse facilitates one-on-one interaction and the development of a
trusting relationship and presents reality in a nonthreatening way. Watching a movie
will allow the client to withdraw further or may escalate the problem by providing too
much external stimulation. Joining a board game with others is beyond the client’s
ability at this time; it would be hard to process all the stimuli. Playing cards alone will
allow the client to withdraw further and does not draw the client into the present; it
would allow the client to continue to hallucinate.

Which response would the nurse make to a client with schizophrenia

lying under a bench in the hall who says, 'God told me to lie here'?
'I didn’t hear anyone talking; come with me to your room.'
'What you heard was in your head; it was your imagination.'
'Come to the dayroom and watch television; you’ll feel better.'
'God wouldn’t tell you to lie in the hall. God wants you to behave reasonably.'

Rationale
The nurse would say, 'I didn’t hear anyone talking; come with me to your room.' The
nurse is focusing on reality and trying to distract and refocus the client’s attention.
'What you heard was in your head; it was your imagination' is too blunt and belittling;
this approach rarely is effective. 'Come to the dayroom and watch television; you’ll feel
better' is false reassurance; the nurse does not know that the client will feel better. 'God
wouldn’t tell you to lie in the hall; God wants you to behave reasonably' may be
interpreted as belittling or an attempt to convince the client that the behavior is
irrational, which is nontherapeutic.

Which approach would the nurse use for a client with schizophrenia who
refuses to eat meals?
Directing the client repeatedly to eat the food
 Explaining to the client the importance of eating
Allowing the client to eat whenever the client is ready

Having a staff member sit with the client in a quiet area during mealtimes

Rationale
The nurse would have a staff member sit with the client in a quiet area during
mealtimes. By sitting with the client during mealtimes, the staff can evaluate how
much the client is eating; this encourages the client to eat and begins the
establishment of a trusting relationship. Fewer distractions may help the client focus
on eating. The client will not follow directions to eat because of the nature of the
illness. Explaining the importance of eating and allowing the client to eat when ready
are both unrealistic and will not ensure adequate intake.

Which response would the nurse make to an upset male client with
schizophrenia who relates that a reporter on television told everyone
that he is 'a bad person'?
'It sounds to me like you’re having some frightening feelings.'
'I’ll call the station to ask why the reporter said that about you.'
'You seem upset by this. Why do you think the reporter said that about you?'

'Sometimes we’re unsure of ourselves. Could you be projecting feelings onto

others?'

Rationale
The nurse would say, 'It sounds to me like you’re having some frightening feelings.'
Noting that the client is having some frightening thoughts encourages exploration of
the client’s concerns and feelings. Saying, 'I’ll call the station,' validates the client’s
ideas of reference and is an inappropriate response. Asking the client why the reporter
said that is reinforcing the delusion and the use of 'why' should be avoided because it
is confrontational. Noting that we all feel unsure sometimes and asking whether the
client is projecting is a premature attempt to provide insight that may increase the
client’s anxiety.

Test-Taking Tip: Never leave a question unanswered. Even if answering is no more

than an educated guess on your part, go ahead and mark an answer. You might be
right, but if you leave it blank, you will certainly be wrong and lose precious points.

Which action would the nurse take for a client who gets down on hands
and knees and says, 'I’m a table'?
State, 'You were never a table before; you’re not a table now.'
Respond, 'You’re safe here in the clinic; you don’t need to be a table.'
Touch the client's arm while saying, 'You must be very frightened to feel this
way.'
Hold out a hand to help the client up while saying, 'You’re not a table; you’re a
person.'

Rationale
The nurse would respond, 'You’re not a table; you’re a person.' This response simply
states reality without attempting to argue the client out of the delusion; actual physical
contact should be initiated by the client. The response, 'You were never a table before;
you aren’t a table now,' denies the client’s feelings and directly attacks the delusion,
forcing the client to defend it. The response, 'You’re safe here in the clinic; you don’t
need to be a table,' is false reassurance; the client does not feel safe and saying this
does not make it so. Although focusing on feelings is appropriate, touching the client’s
arm could be frightening and overwhelming.

Test-Taking Tip: Multiple-choice questions can be challenging, because students think

that they will recognize the right answer when they see it or that the right answer will
somehow stand out from the other choices. This is a dangerous misconception. The
more carefully the question is constructed, the more each of the choices will seem like
the correct response.

Which mental health client would be at highest risk for assaultive

behavior?
Uses profane language
Touches people excessively
Exhibits a sudden withdrawal
Experiences command hallucinations

Rationale
The client who experiences command hallucinations would be at the highest risk.
Command hallucinations are dangerous because they may influence the client to
engage in behaviors that are dangerous to self or others. Although profane language,
excessive touching of others, and withdrawn behavior may all be cause for concern,
none are as dangerous as command hallucinations.

Which priority parameter would the nurse monitor in a young adult

client with schizophrenia who says, 'The voices in heaven are telling me
to come home to God'?
Disturbed self-esteem
Potential for self-harm
Dysfunctional verbal communication
Impaired perception of environmental stimuli

Rationale
The nurse would monitor the potential for self-harm. Client safety always is a priority,
and command hallucinations increase the risk of injury. Although promoting self-
esteem is important, this is not a priority at this time. There are no data to support the
need to focus on the client’s ability to verbally communicate. Verbal hallucinations
occur within the individual; they are not precipitated by an environmental stimulus.
Illusions are precipitated by an environmental stimulus.

To increase involvement in unit activities, which response would the

nurse make to a withdrawn client with schizophrenia who has auditory
hallucinations?
'You’ll get a reward if you go to the gym.'
'Would you like to participate in the group walk today?'
'Those voices you hear would like it if you did a little exercise.'

'There’s a positive relationship between exercise and good mental health.'

Rationale
The nurse would say, 'Would you like to participate in the group walk today?' This
response invites the client to walk, and the client can comply without making a verbal
decision. A client with schizophrenia is often ambivalent, rendering decision-making
difficult. A withdrawn client with hallucinations will not be motivated by rewards.
Saying that the voices want the client to exercise supports and validates the client’s
hallucinations. A withdrawn client with hallucinations needs simple concrete
instructions, not rationale for exercise and good mental health.

Which factor in the history would indicate a potential for recovery in a

client newly diagnosed with schizophrenia?
Vague prepsychotic symptoms
Brain abnormalities on a positron emission tomography (PET) scan
Insidious onset of the client’s illness
 A relative who also has schizophrenia

Rationale
The presence of vague prepsychotic symptoms indicates a greater chance of recovery.
The presence of vague prepsychotic symptoms is associated with decreased morbidity
related to schizophrenia. Brain abnormalities on a PET scan, insidious onset of the
client’s illness, and a relative who also has schizophrenia tend to contribute to a poor
prognosis.

Which short-term outcome would the nurse add to the plan of care for a
client with schizophrenia who is in a catatonic, vegetative state?
Talking with peers
Performing activities of daily living
Completing unit activities and assignments
Ingesting adequate fluid and food with assistance

Rationale
The short-term outcome is to ingest adequate fluid and food with assistance. A client
in a vegetative state may not eat or drink without assistance; fluids and foods are basic
physiological needs that are necessary to prevent malnutrition and starvation;
therefore, the intake of adequate fluid and food is a short-term goal. The client is in
total withdrawal; talking with peers, performing activities of daily living, and
completing activities and assignments are not short-term outcomes at this time.

Test-Taking Tip: Answer every question. A question without an answer is always a

wrong answer, so go ahead and guess.

After the nurse begins the first meeting with an introduction of all
participants in group therapy for clients with schizophrenia, which
action would the nurse take next?
Ask the clients what they hope to gain from the meetings.
Allow the clients to discuss anything they wish to bring up.
Have each of the clients identify a specific concern and then discuss each
concern.
Share with the clients the purpose of the meetings and explain the rules of
behavior.

Rationale
The nurse would share with the clients the purpose of the meetings and explain the
rules of behavior. Sharing the purpose of the meeting and explaining the rules is the
most therapeutic option, because it sets both the parameters of discussion and limits
on behavior. Asking clients what they hope to gain is not what the nurse would do
next. This would occur later depending upon the group dynamics. Allowing clients
with schizophrenia to bring up any topic could cause chaos in the group. Having each
client express and discuss a concern is not therapeutic for a group of clients with the
diagnosis of schizophrenia; a structured process is needed because of the disruption of
the cognitive processes.

Test-Taking Tip: Pace yourself when taking practice quizzes. Because most nursing
exams have specified time limits, you should pace yourself during the practice testing
period accordingly. It is helpful to estimate the time that can be spent on each item
and still complete the examination in the allotted time. You can obtain this figure by
dividing the testing time by the number of items on the test. For example, a 1-hour
(60-minute) testing period with 50 items averages 1.2 minutes per question.

1 topics covered

Cognition - Psychosis Intermediate

HESI Concept / Psychological

Novice Intermed. Prof. Q's

 
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