Psychotic disorders

A nurse is providing care for a client with a history of schizophrenia who's experiencing hallucinations. The health care provider orders 200 mg of haloperidol orally or I.M. every 4 hours as needed. What is the nurse's best action?

• Call the health care provider to clarify the order because the dosage is too high.

The nurse should clarify the order with the health care provider because the dosage is too high (normal dosage ranges from 5 to 10 mg daily

A nurse is planning care for a regressed, chronically ill client diagnosed with schizophrenia. What is the most appropriate milieu?

nurturance and supportive interaction focusing on individual needs

The nurse is reviewing laboratory values of a client receiving clozapine. Which lab value does the nurse immediately report to the health care provider (HCP)?

white blood cell (WBC) count of 3500/µL (3.5 × 10⁹/L)

A nurse is monitoring a client who appears to be hallucinating. The client is gesturing at a figure on the television and appears agitated with speech containing paranoid content. Which nursing interventions are appropriate at this time? Select all that apply.

• Reassure the client that there is no danger.

• Acknowledge the presence of the hallucinations.

• Give simple commands in a calm voice.

A client who is experiencing hallucinations asks if a nurse hears the voices saying that the client should never have been born. The nurse's most appropriate response would be:

"I don't hear any voices, but I believe you can hear them."

• insomnia

• headaches

• transient mild anxiety

A client with chronic schizophrenia has received 10 mg of fluphenazine hydrochloride PO q.i.d. Now the client has a temperature of 102° F (38.9° C), a heart rate of 120 beats/minute, a respiratory rate of 20 breaths/minute, and a blood pressure of 210/140 mm Hg. Because the client is also confused and incontinent, the nurse suspects neuroleptic malignant syndrome. What steps should the nurse take?

Withhold the client's next dose of fluphenazine, call the health care provider, and monitor the client's vital signs.

When conducting a mental status examination with a newly admitted client who has a diagnosis of paranoid schizophrenia, the client states, “I’m being followed; it’s not safe. They are monitoring my every move.” In which area of the mental status examination should the nurse document this information?

thought content

A client is brought to the hospital by the spouse, who states that the client has refused all meals for the past week and accused the spouse of trying to poison the client. During the initial interview, the client's speech, only partly comprehensible, reveals that the client's thoughts are controlled by delusions that the client is possessed by the devil. A health care provider diagnoses paranoid schizophrenia. Paranoid schizophrenia is best described as a disorder characterized by:

preoccupation with persecutory delusions, anxiety, anger, and potential for violence.

A client perceives that their roommate’s stuffed animal is their own dog at home. The nurse determines that this misperception of reality (illusion) is improving when the client makes which statement?

"Jan's stuffed dog looks somewhat like my dog."

A nurse is caring for a client with schizophrenia. Which outcome requires revising the client's care plan?

The client spends more time alone.

The nurse should judge client education regarding valproic acid as effective if the client states which statement?

"I might need to take the valproic acid for a long time."

The nurse is planning the care of a client with schizophrenia. The nurse understands that the client will need the most extensive laboratory monitoring regimen if which medication is prescribed?

clozapine

A client is about to be discharged with a prescription for the antipsychotic agent haloperidol, 10 mg by mouth twice per day. During a discharge teaching session, a nurse should provide which instruction to the client?

Apply a sunscreen before exposure to the sun.Take the medication 1 hour before a meal.

A client’s nursing care plan includes the following prescription: “Assess for auditory hallucinations.” What behavior would suggest to the nurse the client may be experiencing auditory hallucinations?

poor eye contact, tilted head, mumbling to self

A client experiencing a schizophrenic episode is hospitalized. The client is attempting to hit and bite the staff. When the nurse phones the health care provider for orders to help calm the client, the nurse anticipates what medication is likely to be ordered?

haloperidol

A client is admitted to the psychiatric emergency department with difficulty sleeping, poor judgment, and incoherent speech. The client reports being a special messenger from the Messiah who needs to be "sacrificed to save the world." Which action should the nurse take first?

Institute suicide precautions.

Which response demonstrates that the parents of a child with newly diagnosed schizophrenia understand their child's diagnosis?

We'll watch our child take the pills and call the health care provider if the child doesn't swallow them."

The nurse is caring for a client taking risperidone 2 mg daily. It is most important for the nurse to follow up on which client statement?

"I'm constantly sick and feel like I always have a fever."

On admission to the psychiatric unit, a client is dressed in a red leotard and an exercise bra and has an assortment of chains and brightly colored scarves on their head, waist, wrists, and ankles. The client shakes the nurse’s hand and says cheerfully, “We need to become better acquainted. I have the world’s greatest intellect and you are probably an intellectual midget.” How can the nurse document the client’s mood in their assessment?

expansive and grandiose

A client who was prescribed clozapine 2 months ago arrives in the clinic and informs the nurse that the they have been feeling extremely fatigued and feverish and has a sore throat. The nurse observes that the client has two small ulcerations of the oropharynx. Which does the nurse suspect may be occurring with this client?

agranulocytosis

A client with a diagnosis of schizophrenia and paranoid personality disorder asks the nurse, "How do I know what's really in those pills?" Which response by the nurse is best?

"How would you feel if I allowed you to open the individual medication wrappers?"

The parents of a 20-year-old client admitted 4 days ago with a diagnosis of paranoid schizophrenia are attending a family psychoeducation group in the hospital. Which statement indicates that the parents understand their child's illness and management?

"Tasks as simple as getting out of bed and showering in the morning may be difficult."

A young client diagnosed with paranoid schizophrenia is talking with the nurse and says, "You know, when I thought everyone was out to get me, I was staying in my apartment all the time. Now, I would like to get out and do things again." What is the best initial response by the nurse?

"What activities did you enjoy in the past?

A client with schizophrenia reports hearing the voices of the client's dead parents. To help the client ignore the voices, the nurse should recommend that the client:

listen to a personal stereo through headphones and sing along with the music.

A client who is taking medication to control schizophrenia asks the nurse to explain the causes of the disorder. The nurse knows that an overactive dopamine system in the brain is one of the leading causes of schizophrenia and tells the client that excessive dopamine activity is responsible for symptoms. Which symptoms is the nurse referring to? Select all that apply.

The nurse is working in a community mental health clinic. A client who is diagnosed with schizophrenia is taking clozapine and reports of a sore throat. What is the most appropriate action for the nurse to take?

Obtain an order for the client to have a white blood cell count drawn.

A nurse is teaching a client about the prescribed drugs, chlorpromazine and benztropine. What evaluation would indicate a therapeutic response to these drugs?

The client is experiencing less psychosis and a decrease in extrapyramidal symptoms.

Bipolar mania

auditory hallucinations, diorganized speech, increased energy levels, poor personal hygiene.

Major depressive disorder

flat affect, poor personal hygiene, thoughts of self harm

Schizophrenia

auditory hallucinations, disorganized speech, poor personal hygiene, thoughts of self harm, persecutory delusions

A client who is taking medication to control schizophrenia asks the nurse to explain the causes of the disorder. The nurse knows that an overactive dopamine system in the brain is one of the leading causes of schizophrenia and tells the client that excessive dopamine activity is responsible for symptoms. Which symptoms is the nurse referring to? Select all that apply

• hallucinations

• suspiciousness

• delusional thinking

A client diagnosed with paranoid personality disorder is hospitalized for physically threatening their spouse because they suspect the spouse is having an affair with a coworker. What approach should the nurse employ with this client?

matter-of-fact

Teaching for clients of child-bearing years who are receiving antipsychotic medications includes which statement?

Continue previous contraceptive use even if you're experiencing amenorrhea.

Which group of characteristics should a nurse expect to see in the client with schizophrenia?

loose associations, grandiose delusions, and auditory hallucinations

A client with schizophrenia tells the nurse, "My intestines are rotted from the worms chewing on them." This statement indicates a:

somatic delusion.

The spouse of a client admitted for treatment of newly diagnosed paranoid schizophrenia visits 2 days after the client’s admission and states to the nurse, “Why aren’t they eating? They’re still talking about their food being poisoned.” Which appraisal by the nurse is most accurate?

Education about the client's medications is needed.

A charge nurse is educating a new nurse on antipsychotic medications. The charge nurse knows teaching has been effective when the new nurse makes which statement?

"Antipsychotic medication depresses the central nervous system by blocking the postsynaptic transmission of dopamine, serotonin, and norepinephrine."

A client with a 5-year history of multiple psychiatric admissions is brought to the emergency department by the police. This client was found wandering the streets disheveled, shoeless, and confused. The client points to the police officer and states, "That person was sent by the devil to kill me." Which response by the nurse is best?

"That sounds scary. That person is a police officer and brought you to the hospital."

A client with schizophrenia is admitted to a health care facility. When collecting data about the client, the nurse should document which symptoms as negative symptoms of schizophrenia? Select all that apply.

• lack of motivation

• apathy

• blunted affect

A client tells a nurse that people from Mars are going to invade the Earth. Which response by the nurse would be therapeutic?

• That must be frightening to you. Can you tell me how you feel about it?"

A client has refused to take a shower since being admitted 4 days earlier and tells a nurse, "There are poison crystals hidden in the showerhead. They'll kill me if I take a shower." Which nursing action is most appropriate?

accepting these fears and allowing the client to take a sponge bath

What is the priority symptom to assess for in the client who is taking risperidone 1 mg, orally twice a day?

orthostatic hypotension

A client is in the withdrawn phase of catatonia due to schizophrenia. This is the client’s first admission to an early psychosis program at an urban hospital. At present, the client is completely stuporous. What is the priority while giving care to the client during this phase of symptoms?

Explain all physical care activities in simple, explicit terms as though expecting a response.

A client's medication order reads, "Thioridazine 200 mg P.O. q.i.d. and 100 mg P.O. PRN" A nurse should:

question the health care provider about the order.

A client is admitted to the emergency department with anxiety and restlessness. The nurse observes the client exhibiting uncontrolled blinking, tremors, and facial stiffness. The client reports taking thioridazine, amitriptyline, and escitalopram at home. What is the priority action by the nurse?

Assess vital signs, and administer oxygen per nasal cannula to maintain a saturation of 95%.

The nurse cares for a client with grandiose delusions. Which intervention(s) should the nurse incorporate into the plan of care? Select all that apply.

Focus on the feeling or meaning of the delusion.Accept the client while not arguing with the delusion.

• Focus on events and topics based in reality.

A nurse is caring for a client who recently starting taking haloperidol. Which client assessment would be a priority for nurse follow up?

neck stiffness with head tilt

A client has catatonic behaviors. Which outcome would indicate a medication has been most effective in improving long-term behavior?

The client:

initiates simple activities without directions.

The nurse is admitting a client to the psychiatric unit. Suddenly, the client states, “They’re all plotting to destroy me. Isn’t that true?” Which would be the most appropriate response?

“Please explain that to me.”

A client reports having thoughts of being followed by foreign agents who are after the client's "secret papers." Which response by the nurse is most appropriate when responding to the client's disturbed thought process?

"I think these thoughts are frightening to you."

Safety concerns lead to the hospitalization of a client with a history of childhood sexual assault and dissociative identity disorder. Which nursing interventions are most important? Select all that apply.

• Initiate precautions for suicide and self-mutilation.

• Support using a notebook to continue communications with alters.

• Provide anxiety management and rest.

• Allow time for processing feelings in a journal.

A client has been hospitalized on the psychiatric-mental health unit on an involuntary basis due to an exacerbation of schizophrenia. When assessing and promoting the client's social support network during this health crisis, the nurse should perform what action?

• Provide education to the client and family about the diverse benefits of a social support network.

Which concept is most important for a nurse to communicate to a client preparing to sign an informed consent for electroconvulsive therapy (ECT)?

"You may experience a time of confusion after the treatment."

A client with schizophrenia who receives fluphenazine develops pseudoparkinsonism and akinesia. What drug should the nurse administer as ordered to minimize this client's extrapyramidal symptoms?

benztropine

A client, diagnosed with Alzheimer’s disease, is a new resident in a long-term care facility. The client has difficulty finding their room and is seen wandering into the room of others. When discussing the situation at a multidisciplinary conference, which client centered actions would the nurse suggest? Select all that apply.

• Ensure that the client has prescribed hearing aids and glasses on throughout the day.

• Place a box with familiar personal items outside the client’s door for visual recognition.

• Assign the client to a room close to the nursing station for closer monitoring.

• Provide verbal cueing as to where the client’s room is located

A client tells the nurse, "Everybody smiles at me because they know that I was chosen by God for this mission." The nurse interprets this statement as which finding?

idea of reference