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HESI RN EXIT CASE STUDY - SCHIZOPHRENIA 1. Based on this assessment, what is the most important nursing interven- tion? A. Establish rapport and trust. B. Assess for hallucinations. C. Maintain adequate social space. D. Plan to give a PRN antipsychotic ANS: A. Establish rapport and trust. 2. What is the most accurate assessment if the client believes that the health- care providers are FBI agents and that there are cameras in his apartment to monitor his moves? A. Hallucinations. B. Delusions. C. Confabulation. D. Thought broadcasting ANS: B. Delusions. 3. Which behavior is characteristic of a thought disorder? A. Blunted affect. B. Irritability. C. Lability of mood. D. Preoccupation with guilty feelings ANS: A. Blunted affect. 4. The nurse understands that schizophrenia can be differentiated from psy- chosis by which assessment? A. Disorganized speech. B. Disorganized behavior. C. Auditory hallucinations. D. Negative symptoms ANS: D. Negative symptoms. 5. Which finding depicts negative symptoms of schizophrenia? A. Difficulty sitting still. B. Rapid and disorganized speech. C. Flat affect and social inattentiveness. D. Delusional statements ANS: C. Flat affect and social inattentiveness. 6. Which nursing problem has priority? A. Ineffective community coping. B. Disturbed thought processes.
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