1. A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this clients safety? A. Assess for medication noncompliance B. Note escalating behaviors and intervene immediately C. Interpret attempts at communication D...
Nur 214 Test 3 Questions and Complete
Solutions
1. A paranoid client presents with bizarre behaviors, neologisms, and thought insertion.
Which nursing action
should be prioritized to maintain this clients safety?
A. Assess for medication noncompliance
B. Note escalating behaviors and intervene immediately
C. Interpret attempts at communication
D. Assess triggers for bizarre, inappropriate behaviors ✅B. Note escalating behaviors
and intervene immediately
2. A client diagnosed with schizoaffective disorder is admitted for social skills training.
Which information
should be taught by the nurse?
A. The side effects of medications
B. Deep breathing techniques to decrease stress
C. How to make eye contact when communicating
D. How to be a leader ✅C. How to make eye contact when communicating
3. A 16-year-old client diagnosed with schizophrenia experiences command
hallucinations to harm others. The
clients parents ask a nurse, Where do the voices come from? Which is the appropriate
nursing reply?
A. Your child has a chemical imbalance of the brain, which leads to altered thoughts.
B. Your childs hallucinations are caused by medication interactions.
C. Your child has too little serotonin in the brain, causing delusions and hallucinations.
D. Your childs abnormal hormonal changes have ✅A. Your child has a chemical
imbalance of the brain, which leads to altered thoughts.
4. Parents ask a nurse how they should reply when their child, diagnosed with
schizophrenia, tells them that
voices command him to harm others. Which is the appropriate nursing reply?
A. Tell him to stop discussing the voices.
B. Ignore what he is saying, while attempting to discover the underlying cause.
C. Focus on the feelings generated by the hallucinations and present reality.
D. Present objective evidence that the voices are not real. ✅C. Focus on the feelings
generated by the hallucinations and present reality.
5. A 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 of this disorder is the
,nurse assessing?
A. Thought insertion
B. Paranoia
C. Magical thinking
D. Delusions of reference ✅D. Delusions of reference
6. A client diagnosed with schizophrenia tells a nurse, The Shopatouliens took my
shoes out of my room last
night. Which is an appropriate charting entry to describe this clients statement?
A. The client is experiencing command hallucinations.
B. The client is expressing a neologism.
C. The client is experiencing a paranoia.
D. The client is verbalizing a word salad. ✅B. The client is expressing a neologism.
7. 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?
A. Delusions of persecution
B. Delusions of influence
C. Delusions of reference
D. Delusions of grandeur ✅B. Delusions of influence
8. A client diagnosed with schizophrenia states, Cant you hear him? Its the devil. Hes
telling me Im going to
hell. Which is the most appropriate nursing reply?
A. Did you take your medicine this morning?
B. You are not going to hell. You are a good person.
C. Im sure the voices sound scary. I dont hear any voices speaking.
D. The devil only talks to people who are receptive to his influence. ✅C. Im sure the
voices sound scary. I dont hear any voices speaking.
9. A client diagnosed with brief psychotic disorder tells a nurse about voices telling him
to kill the president. Which nursing diagnosis should the nurse prioritize for this client?
A. Disturbed sensory perception
B. Altered thought processes
C. Risk for violence: directed toward others
D. Risk for injury ✅C. Risk for violence: directed toward others
10. Which nursing intervention would be most appropriate when caring for an acutely
agitated client with
paranoia?
A. Provide neon lights and soft music.
B. Maintain continual eye contact throughout the interview.
C. Use therapeutic touch to increase trust and rapport.
, D. Provide personal space to respect the clients boundaries. ✅D. Provide personal
space to respect the clients boundaries.
11. Which nursing behavior will enhance the establishment of a trusting relationship with
a client diagnosed
with schizophrenia?
A. Establishing personal contact with family members.
B. Being reliable, honest, and consistent during interactions.
C. Sharing limited personal information.
D. Sitting close to the client to establish rapport. ✅B. Being reliable, honest, and
consistent during interactions.
12. A client diagnosed with schizophrenia states, My psychiatrist is out to get me. Im
sad that the voice is
telling me to stop him. What symptom is the client exhibiting, and what is the nurses
legal responsibility
related to this symptom?
A. Magical thinking; administer an antipsychotic medication
B. Persecutory delusions; orient the client to reality
C. Command hallucinations; warn the psychiatrist
D. Altered thought processes; call an emergency treatment team meeting ✅C.
Command hallucinations; warn the psychiatrist
13. Which statement should indicate to a nurse that an individual is experiencing a
delusion?
A. Theres an alien growing in my liver.
B. I see my dead husband everywhere I go.
C. The IRS may audit my taxes.
D. Im not going to eat my food. It smells like brimstone. ✅A. Theres an alien growing in
my liver.
14. A client diagnosed with schizophrenia is slow to respond and appears to be listening
to unseen others. Which medication should a nurse expect a physician to order to
address this type of symptom?
A. Haloperidol (Haldol) to address the negative symptom
B. Clonazepam (Klonopin) to address the positive symptom
C. Risperidone (Risperdal) to address the positive symptom
D. Clozapine (Clozaril) to address the negative symptom ✅C. Risperidone (Risperdal)
to address the positive symptom
15. A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol), 50
mg bid; benztropine
(Cogentin), 1 mg prn; and zolpidem (Ambien), 10 mg HS. Which client behavior would
warrant the nurse to
administer benztropine?
A. Tactile hallucinations
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