NUR317 Final Exam
A paranoid client presents with bizarre behaviors, neologisms,
and thought insertion. Which is the priority nursing action to
maintain this client's safety? - CORRECT ANSWER Note
escalating behaviors and intervene immediately.
A client diagnosed with Schizoaffective Disord...
A paranoid client presents with bizarre behaviors, neologisms,
and thought insertion. Which is the priority nursing action to
maintain this client's safety? - CORRECT 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? - CORRECT ANSWER How to make eye contact when
communicating.
A 16-year old client diagnosed with Schizophrenia experiences
command hallucinations to harm others. The client's parents ask
the nurse, "Where do the voices come from?" Which is the
appropriate nursing reply? - CORRECT ANSWER "Your child
has a chemical imbalance of the brain, which leads to altered
thoughts."
Parents ask the nurse how they should reply when their child,
diagnosed with Schizophrenia, tells them that voices are
commanding him to harm others. Which is the appropriate nursing
reply? - CORRECT ANSWER "Focus on the feelings generated
by the hallucinations and present 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? - CORRECT ANSWER
Delusions of reference.
,A client diagnosed with Schizophrenia tells the nurse, "The
'Shoptouliens' took my shoes out of my room last night." Which is
the correct charting entry to describe this client's statement? -
CORRECT ANSWER "The client is expressing a neologism."
During an admission assessment, a nurse asks a client
diagnosed with schizophrenia, "Have you ever felt that certain
objects or persons have control over your behavior?" The nurse is
assessing for which type of thought disruption? - CORRECT
ANSWER Delusions of influence.
A client diagnosed with Schizophrenia states, "Cant you hear
him? It's the devil. He's telling me I'm going to hell." Which is the
most appropriate nursing reply? - CORRECT ANSWER "I'm
sure the voices sound scary. I don't hear any voices speaking."
A client diagnosed with brief psychotic disorder tells the nurse
about voices telling him to kill the president. Which nursing
diagnosis should the nurse prioritize for this client? - CORRECT
ANSWER Risk for violence; other-directed.
Which nursing intervention is most appropriate when caring for an
acutely agitated client with paranoia? - CORRECT ANSWER
Provide personal space to respect the client's boundaries.
Which nursing behavior will enhance the establishment of a
trusting relationship with a client diagnosed with schizophrenia? -
CORRECT ANSWER Being reliable, honest, and consistent
during interactions.
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." Which
symptoms is the client exhibiting, and what is the nurses's legal
responsibility related to the symptom? - CORRECT ANSWER
Command hallucinations, warn the psychiatrist.
, Which statement indicates to the nurse that a client is
experiencing a delusion? - CORRECT ANSWER "There's an
alien growing in my liver."
A client diagnosed with Schizophrenia is slow to respond and
appears to be listening to unseen others. Which medication
should the nurse expect a physician to oder to address this type
of symptom? - CORRECT ANSWER Risperidone (Risperdal) to
address positive symptoms.
A client diagnosed with Schizophrenia. A physician orders Haldol,
50 mg BID, Cogentin 1 mg pro, and Ambient 10 mg HS. Which
client behavior would warrant the nurse to administer Cogentin? -
CORRECT ANSWER Restlessness and muscle rigidity.
The nurse for a client who is experiencing a flat affect, paranoia,
anhedonia, anergia, neologisms and echolalia. Which statement
correctly differentiates the client's positive and negative
symptoms of Schizophrenia? - CORRECT ANSWER Paranoia,
neologism, and echolalia are positive symptoms of schizophrenia.
An elderly client diagnosed with Schizophrenia takes an
antipsychotic and a beta-adrenergic blocking agent for
hypertension. Understanding the combined side effects of these
drugs, which statement by the nurse is most appropriate? -
CORRECT ANSWER "Rise slowly when you change position
from lying to sitting or sitting too standing."
A client diagnosed with Schizophrenia is prescribed Clozaril.
Which client symptoms related to the side effects of this
medication should prompt the nurse to intervene immediately? -
CORRECT ANSWER Sore throat, fever, and malaise.
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