Mental health exam 4

Nurse Dorothy is evaluating care of a client with schizophrenia; the nurse should keep which point in mind?

• Frequent reassessment is needed and is based on the client's response to treatment.

• The family does not need to be included in the care because the client is an adult.

• The client is too ill to learn about his illness.

• Relapse is not an issue for a client with schizophrenia.

Gio told his nurse that the FBI is monitoring and recording his every movement and that microphones have been placed in the unit walls. Which action would be the most therapeutic response?

• Confront the delusional material directly by telling Gio that this simply is not so.

• Tell Gio that this must seem frightening to him but that you believe he is safe here.

• Tell Gio to wait and talk about these beliefs in his one-on-one counseling sessions.

• Isolate Gio when he begins to talk about these beliefs.

Which of the following client behaviors documented in Gio’s chart would validate the nursing diagnosis of Risk for other-directed violence?

• Gio's description of being endowed with superpowers.

• Frequent angry outburst noted toward peers and staff.

• Refusal to eat cafeteria food.

• Refusal to join in group activities.

A patient is diagnosed as having disorganized schizophrenia. Which behaviors would the Nurse most likely assess in the client?

• Absence of acute symptoms impaired role function.

• Extreme social withdrawal, odd mannerisms, and behavior.

• Psychomotor immobility; presence of waxy flexibility.

• Suspiciousness toward others increased hostility.

Jaime has a diagnosis of schizophrenia with negative symptoms. In planning care for the client, Nurse Brienne would anticipate a problem with:

• Auditory hallucinations

• Bizarre behaviors

• Ideas of reference

• Motivation for activities

A client tells the nurse that psychotropic medicines are dangerous and refuses to take them. Which intervention should the nurse use first?

• Ask the client about any previous problems with psychotropic medications.

• Ask the client if an injection is preferable.

• Insist that the client takes medication as prescribed.

• Withhold the medication until the client is less suspicious.

Nurse Arya assesses for evidence of positive symptoms of schizophrenia in a newly admitted client. Which of the following symptoms are considered positive evidence? Select all that apply.

• Anhedonia

• Delusions

• Flat affect

• Hallucinations

• Loose associations

Since admission 4 days ago, a client has refused to take a shower, stating, “There are poison crystals hidden in the showerhead. They’ll kill me if I take a shower.” Which nursing action is most appropriate?

• Dismantling the showerhead and showing the client that there is nothing in it.

• Explaining that other clients are complaining about the client’s body odor.

• Asking a security officer to assist in giving the client a shower.

• Accepting these fears and allowing the client to take a sponge bath.

A client with paranoid personality disorder is admitted to a psychiatric facility. Which remark by the nurse would best establish rapport and encourage the client to confide in the nurse?

• “I get upset once in a while, too.”

• “I know just how you feel. I’d feel the same way in your situation.”

• “I worry, too, when I think people are talking about me.”

• “At times, it’s normal not to trust anyone.”

How soon after chlorpromazine (Thorazine) administration should the nurse expect to see a client’s delusional thoughts and hallucinations eliminated?

• Several minutes

• Several hours

• Several days

• Several weeks