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NUR317 Final Exam With Complete Solution
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NUR317 Final Exam With Complete SolutionA paranoid client displays bizarre behaviors, neologisms, and thought insertion. Which
is the priority nursing action to maintain this client's safety? - Answer Note escalating
behaviors and intervene immediately.
A client diagnosed with Schizoaffective Disorder is admitted for social skills training.
Which information should be taught by the nurse? - Answer How to make eye contact
when communicating.
A 16-year-old client is admitted with a diagnosis of Schizophrenia and reports command
hallucinations commanding the client to harm others. The client's parents ask the nurse,
"Where do the voices come from?" Which is the appropriate nursing response? Answer
"Your child has a chemical imbalance of the brain, which leads to altered thoughts."
Parents ask the nurse how they should respond when their child with Schizophrenia
tells them that voices are telling him to hurt others. What is the correct nursing
response? Response "Address the feelings produced by the hallucinations and bring in
reality."
The nurse is assessing a client diagnosed with Schizophrenia. The nurse asks the client
"Do you receive special messages from certain sources, such as the television or
radio?" Which potential symptom is the nurse assessing? - Answer Delusions of
reference.
A client diagnosed with Schizophrenia tells the nurse, "The 'Shoptouliens' took my
shoes out of my room last night." Which of the following is the appropriate charting entry
to describe this client's utterance? - Answer "The client is utilizing a neologism."
A nurse is performing an admission assessment on a client diagnosed with
schizophrenia. The nurse asks the client, "Have you ever felt that certain objects or
persons have control over your behavior?" What type of thought disruption is the nurse
assessing? Answser Delusions of influence.
,A patient with Schizophrenia states, "Cant you hear him? It's the devil. He's telling me
I'm going to hell." Choose the best nursing response. - Response "I'm sure the voices
sound scary. I don't hear any voices speaking."
A client is diagnosed with brief psychotic disorder and tells the nurse that voices are
instructing him to kill the president. What nursing diagnosis should the nurse recognize
as the priority for this client? Answer Risk for violence; other-directed.
Which of the following nursing interventions is most appropriate when caring for an
acutely agitated paranoid client? Answer Provide personal space to respect the
boundaries of the client.
Which nursing behavior will help to establish a trusting relationship with a client who is
diagnosed with schizophrenia? Response Being reliable, honest and predictable in the
relationship.
A client diagnosed with Schizophrenia states, "My president is out to get me. I'm sad
that the voice is telling me to stop him." Identify the symptoms the client is presenting
and what the nurse's legal responsibility is related to the symptom. - Answer Command
hallucinations, warn the psychiatrist.
Which statement indicates to the nurse that a client is experiencing a delusion? -
Answer "There's an alien growing in my liver."
A client diagnosed with Schizophrenia exhibits responses that are very slow and
appears to be listening to unseen others. For a symptom of this type, what medication
might the nurse expect a physician to order? Answer Risperidone (Risperdal) is utilized
for positive symptoms.
A client is diagnosed with Schizophrenia. The physician orders Haldol 50 mg BID,
Cogentin 1 mg pro, and Ambient 10 mg HS. Which client behavior would require the
nurse to administer Cogentin? -Answer Restlessness and muscle rigidity.
, The nurse is caring for a client who demonstrates flat affect, paranoia, anhedonia,
anergia, neologisms, and echolalia. Which statement accurately identifies the client's
positive and negative symptoms of Schizophrenia? -Answer Paranoia, neologism, and
echolalia are positive symptoms of schizophrenia.
An older client with Schizophrenia is taking an antipsychotic and a beta-adrenergic
blocking agent for hypertension. Based on understanding the combined side effects of
these drugs, which statement by the nurse is most appropriate? - Answer "Rise slowly
when you change position from lying to sitting or sitting too standing."
The client is receiving Clozaril for Schizophrenia. For which of the following client
symptoms related to the side effects of this medication would the nurse need to
intervene immediately? Answer Sore throat, fever, malaise.
The nurse is performing an admission assessment when she discovers that a client,
diagnosed with Schizophrenia, reports allergies including penicillin, Compazine, and
bee stings. Based on this assessment data, which of the following antipsychotic
medications would be contraindicated? Answer Thioridazine (Mellaril), because of
cross-sensitivity among phenothiazines.
A college student is not attending classes, isolates self because of hearing voices, and
yells accusations at fellow students. Based on this information, which should be the
nurses's priority nursing diagnosis? - Answer Risk for other-directed violence R/T
yelling accusations.
A client has been recently admitted to an inpatient psychiatric unit. What intervention
should the nurse plan to utilize to decrease the client's preoccupation with delusional
thinking? Answer Focus on feelings suggested by the delusions.
A client states, "I hear voices that tell me that I am evil." What discharge outcome
related to the client symptoms should the nurse anticipate for this client? - Answer The
client will identify events that increase anxiety and illicit hallucinations.
A client who has recently been admitted has been receiving thioridazine (Mellaril) for 2
years with good symptom control. Symptoms present at the time of admission included
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