Passpoint-psychotic disorders Questions With Answers, Exams of Nursing

Download Passpoint-psychotic disorders Questions With Answers and more Exams Nursing in PDF only on Docsity! Passpoint-psychotic disorders Questions With Answers A well-known client suffers a psychotic break and is admitted to the psychiatric unit. A large group of reporters with cameras is camped out in the hospital parking lot. As a nurse walks to the employee parking after her shift, a reporter asks if she knows anything about the client's conditio Question 1See full question A client with schizophrenia repeatedly uses profanity during an activity therapy session. Which response by the nurse is appropriate? You Selected: • "Your behavior won't be tolerated. Go to your room immediately." Correct response: • "Your cursing is interrupting the activity. Take time out in your room for 10 minutes." Explanation: Remediation: Question 2See full question When conducting a mental status examination with a newly admitted client who has a diagnosis of paranoid schizophrenia, the client states, “I am being followed; it is not safe. They are monitoring my every move.” In which area of the mental status examination should the nurse document this information? You Selected: • insight Correct response: • thought content Explanation: Question 1See full question A client with delusional thinking who is overweight and tends to eat when stressed shows a lack of interest in eating at meal times. She states that she is unworthy of eating and that her children will die if she eats. Which nursing action is most appropriate for this client? • alcohol withdrawal Correct response: • alcohol withdrawal Explanation: Remediation: Question 7See full question The client with a diagnosis of schizophrenia spends much of the morning in the bedroom but seeks out the nurse for brief interactions throughout the morning. Which goal should the nurse assist the client with achieving in the afternoon? The client will: You Selected: • engage three of his peers in a card game. Correct response: • help put a puzzle together. Explanation: Remediation: Question 8See full question The client with a diagnosis of schizophrenia walks into group naked. The nurse should: You Selected: • lead the client to his room and help him dress if he needs assistance. Correct response: • lead the client to his room and help him dress if he needs assistance. Explanation: Remediation: Question 9See full question One of the clients in group with a dual diagnosis of chronic schizophrenia and alcohol abuse states, “I am not going to take medicine every day.” Which response by the nurse would be mostappropriate? You Selected: • “I hear you say that you do not like taking medication daily.” Correct response: • “I hear you say that you do not like taking medication daily.” Explanation: Remediation: Question 10 See full question While planning the care for a client with paranoid delusions, which of the following will be the nurse’s initial goal for the client? You Selected: • Establish trust with staff. Correct response: • Establish trust with staff. Explanation: Remediation: Question 3See full question One of the clients in group with a dual diagnosis of chronic schizophrenia and alcohol abuse states, “I am not going to take medicine every day.” Which response by the nurse would be mostappropriate? You Selected: • “Let us discuss this tomorrow if we have time.” Correct response: • “I hear you say that you do not like taking medication daily.” Explanatio n: Remediati on: Question 4See full question The client tells the nurse that she stopped taking olanzapine 2 weeks ago because she is better and wants “to make it on my own without this darned medicine.” What would be the nurse’s mosttherapeutic response? You Selected: • “You have told me about other times like this when you stopped taking your medication and you got sick again. You should know better by now.” Correct response: • ”I know you get tired of taking the medication, especially when you are doing well. Is there any special reason you decided to stop right now?” Explanation: Remediation: Question 5See full question The guardian of a client diagnosed with schizophrenia indicates to the nurse a concern that the client is at risk for suicide. Which question to the client would the nurse utilize to determine the seriousness of the suicidal idealization? You Selected: • “Are you planning on hurting yourself?” Correct response: Question 1 See full question A client who takes neuroleptic medication for treatment of chronic schizophrenia is admitted to the psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, and diaphoresis. Which life- threatening reaction do these findings suggest? You Selected: • Neuroleptic malignant syndrome Correct response: • Neuroleptic malignant syndrome Explanation: Remediation: Question 2 See full question A client with a diagnosis of borderline personality disorder is admitted to the psychiatric unit. The nurse expects the assessment to reveal: Explanation: Remediation: Question 2See full question A well-known client suffers a psychotic break and is admitted to the psychiatric unit. A large group of reporters with cameras is camped out in the hospital parking lot. As a nurse walks to the employee parking after her shift, a reporter asks if she knows anything about the client's condition. What is the most appropriate response? You Selected: • "All I can say is that the client is safe and stable." Correct response: • "I can't answer your question." Explanation: Question 3See full question Which response demonstrates that the parents of a child with newly diagnosed schizophrenia understand their child's diagnosis? You Selected: • "As long as we're understanding and supportive, he'll eventually be fine." Correct response: • "We'll watch him swallow his daily pills and call the physician if he doesn't." Explanation: Remediation: Question 4See full question A nurse is planning care for a regressed, chronically ill client diagnosed with schizophrenia. What is the most appropriate milieu? You Selected: • nurturance and supportive interaction focusing on individual needs Correct response: • nurturance and supportive interaction focusing on individual needs Explanation: Remediation: Question 5See full question During a home visit, a client who is 75 years of age tells the community health nurse, “Lately I am getting forgetful about things. For one thing, I cannot remember names. Do you think I am getting Alzheimer’s disease?” Which response by the nurse is the most therapeutic? You Selected: • “Most people your age have this problem. It is not Alzheimer’s disease.” Correct response: • “Tell me more about your forgetfulness. It is not unusual for forgetfulness to occur.” Explanation: A client with schizophrenia states, "I hear the voice of King Tut." Which response by the nurse is therapeutic? You Selected: • "I don't hear the voice, but I know you hear what sounds like a voice." Correct response: • "I don't hear the voice, but I know you hear what sounds like a voice." Explanation: Remediation: Question 2See full question A client with a diagnosis of borderline personality disorder is admitted to the psychiatric unit. The nurse expects the assessment to reveal: You Selected: • unpredictable behavior and intense interpersonal relationships. Correct response: • unpredictable behavior and intense interpersonal relationships. Explanation: Remediation: Question 3See full question A client begins clozapine therapy after several other antipsychotic agents fail to relieve her psychotic symptoms. The nurse instructs her to return for weekly white blood cell (WBC) counts to assess for which adverse reaction? You Selected: • Granulocytopenia Correct response: • Granulocytopenia Explanation: Remediation: Question 4See full question While pacing in the hall, a client with schizophrenia runs to a nurse and asks, "Why are you poisoning me? I know you work for Central Thought Control! You can keep my thoughts. Give me back my soul!" How should the nurse respond during the early stage of the therapeutic process? You Selected: • "I'm a nurse, and you're a client in the hospital. I'm not going to harm you." Correct response: • "I'm a nurse, and you're a client in the hospital. I'm not going to harm you." Explanation: Remediation: Question 5See full question A client diagnosed with borderline personality disorder has self- inflicted cuts on her arms. The nurse is assessing the client for the risk of suicide. What should the nurse ask the client first? You Selected: • visual hallucination Correct response: • idea of reference Explanation: Remediation: Question 11See full question A health care provider prescribes haloperidol p.o. 1 mg t.i.d. When assessing the client for extrapyramidal adverse effects, which nursing measures would be initiated? Select all that apply. You Selected: • Observe for increased pacing and restlessness. • Closely monitor vital signs, especially temperature. • Monitor for signs and symptoms of urticaria. Correct response: • Closely monitor vital signs, especially temperature. • Observe for increased pacing and restlessness. • Provide the client with sugar free hard candy. Explanation: Remediation: Question 12See full question The primary care provider prescribes risperidone 1 mg orally, two times a day for a client from a group home admitted to the hospital with severe anti- social behavior. The nurse determines that this dose is: You Selected: • Too low for the client. Correct response: • Typical when initiating therapy. Explanation: Remediation: Question 13See full question A client comes to the mental health clinic 2 days after being discharged from the hospital. The client was given a 1-week supply of clozapine. Which client statement indicates an accurate understanding of the nurse's teaching about this medication? You Selected: • "I need to keep my appointment here at the clinic this week for a blood test." Correct response: • "I need to keep my appointment here at the clinic this week for a blood test." Explanation: Remediation: Question 14See full question A client taking clozapine states, “I do not like feeling so sedated during the day. I can hardly keep my eyes open.” Which response by the nurse would be most appropriate? You Selected: • "Let us talk to your health care provider about taking most of the drug at bedtime.” Correct response: • "Let us talk to your health care provider about taking most of the drug at bedtime.” Explanation: Remediation: Question 15See full question During a home visit, the nurse discovers that the client is less verbal, less active, less responsive to directions, severely anxious, and more stuporous. The nurse interprets these findings to indicate that the client needs which intervention? You Selected: • an increase in medication Correct response: • immediate medical evaluation Explanation: Remediation: Question 16See full question The nurse is observing a client who is sitting alone in the day room and is intently focused on a nearby empty chair. Suddenly the client begins laughing hysterically and making frantic hand gestures at the chair. When the nurse approaches the client, he/she looks over at the chair, whispers something unintelligible, and shakes his/her head. How would the nurse best assess the client’s behavior in this situation? You Selected: • A hallucination Correct response: • A hallucination Explanation: Remediation: Question 17See full question The parents of a teenager recently diagnosed with schizophrenia ask the nurse about whether their other children will be susceptible as well. The nurse explains that schizophrenia is caused by: Remediation: Question 9 See full question The guardian of a client diagnosed with schizophrenia indicates to the nurse a concern that the client is at risk for suicide. Which question to the client would the nurse utilize to determine the seriousness of the suicidal idealization? You Selected: • “Are you planning on hurting yourself?” Correct response: • “Are you planning on hurting yourself?” Explanation: Remediation: Question 10 See full question 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? You Selected: • Obtain an order for the client to have a white blood cell count drawn. Correct response: • Obtain an order for the client to have a white blood cell count drawn. Question 1 See full question Which concept is most important for a nurse to communicate to a client preparing to sign an informed consent for electroconvulsive therapy (ECT)? You Selected: • "You may experience a time of confusion after the treatment." Correct response: • "You may experience a time of confusion after the treatment." Explanation: Remediation: Question 2 See full question A client diagnosed with schizophrenia is being switched to risperidone long-acting injection. He is told that he will remain on his oral dose of risperidone daily for approximately 1 month. The client says, "I did not have to take pills when I was on fluphenazine shots in the past." The nurse should tell the client: You Selected: • "Risperidone long-acting injection initially takes a little longer to reach the ideal blood level." Correct response: • "Risperidone long-acting injection initially takes a little longer to reach the ideal blood level." Explanation: Remediation: Question 3 See full question A client diagnosed with schizophrenia is being discharged on aripiprazole 5 mg every night. When developing the teaching plan about the most common adverse effects, which information should the nurse include? Select all that apply. You Selected: • torticollis • insomnia • headaches Correct response: • headaches • transient mild anxiety • insomnia Explanation: Remediation: Question 4 See full question Which intervention is essential when caring for a client who is experiencing delirium? You Selected: • identifying the underlying causative condition or illness Correct response: • identifying the underlying causative condition or illness Explanation: Remediation: Question 5 See full question After several months of taking olanzapine, the client reports that he is no longer hearing voices of any kind. Which statement would confirm that the client is developing insight into his illness? You Selected: • "I did not realize how sick I could get from a chemical brain imbalance." Correct response: • "I did not realize how sick I could get from a chemical brain imbalance." Explanation: Remediation: Question 6 See full question Which clinical manifestation should alert the nurse to lithium toxicity? You Selected: • lethargy and weakness with vomiting Correct response: • lethargy and weakness with vomiting Explanation: Remediation: Question 7 See full question A client is admitted to the psychiatric unit exhibiting extreme agitation, disorientation, and incoherence of speech with frantic and aimless physical activity and grandiose delusions. Which of the following would the highest priority goal in planning nursing interventions? You Selected: • The client will show no self-harm or harm to staff. Correct response: • The client will show no self-harm or harm to staff. Explanation: Remediation: Question 8 See full question A client is sitting in the dining area and laughing out loud, shaking her head, and whispering behind her hand. Suddenly the client begins banging her head against the wall. Which of the following interventions by the nurse is most appropriate? You Selected: Correct response: • The client spends more time by himself. Explanation: Remediation: Question 6See full question Positive symptoms of schizophrenia include: You Selected: • flat affect, avolition, and anhedonia. Correct response: • hallucinations, delusions, and disorganized thinking. Explanation: Remediation: Question 7See full question A client with a diagnosis of schizophrenia and who is paranoid asks the nurse, "How do I know what is really in those pills?" The best response is to: You Selected: • say, "You know this is your medicine." Correct response: • allow the client to open the individual medication wrappers. Explanation: Remediation: Question 8See full question A nurse is caring for a client with schizophrenia whose symptoms are managed with medications. The client reveals that he's doing so well that he doesn't think he needs to take medication anymore. Which response indicates that the nurse understands the client's diagnosis? You Selected: • "You have to take the pills the physician has ordered for you." Correct response: • "The medications are helping you. If you suddenly stop taking them, you could get sick again." Explanation: Remediation: Question 9See full question A client with a diagnosis of antisocial personality disorder has a potential for violence and aggressive behavior. Which short-term client outcome is most appropriate for the nurse to include in the plan of care? You Selected: • Discuss feelings of anger with staff. Correct response: • Discuss feelings of anger with staff. Explanation: Remediation: Question 10See full question A young client diagnosed with 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? You Selected: • "How much money can you spend?" Correct response: • "What activities did you enjoy in the past?" Explanation: Remediation: Question 11See full question When conducting a mental status examination with a newly admitted client who has a diagnosis of paranoid schizophrenia, the client states, “I am being followed; it is not safe. They are monitoring my every move.” In which area of the mental status examination should the nurse document this information? You Selected: • thought content Correct response: • thought content Explanation: Question 12See full question An outpatient client who has a history of paranoid schizophrenia and chronic alcohol dependency has been taking risperidone for several months. She reports that she stopped drinking 4 days ago. The client is very frightened by the tactile hallucinations of bugs crawling under her skin. Which factor should the nurse incorporate into the plan of care when explaining the tactile hallucinations? You Selected: • alcohol withdrawal Correct response: • alcohol withdrawal Explanation: Remediation: Question 13See full question The nurse hands the medication cup to a client who is psychotic and exhibiting concrete thinking, and tells the client to take his medicine. The client takes the cup, holds it in his hand, and stares at it. What should the nurse do next? You Selected: • Tell the client that if he/she does not comply with the rules, you will inform the doctor. Correct response: • Respect the client's need for personal space and avoid physical contact with the client. Explanation: Remediation: Question 19See full question A client experiencing a schizophrenic episode is hospitalized. The client is attempting to hit and bite the staff. When the nurse phones the primary care provider for orders to help calm the client, the nurse anticipates what medication is likely to be ordered? You Selected: • Lithium carbonate Correct response: • Haloperidol Explanation: Remediation: Question 20See full question A nurse caring for a client with schizophrenia goes into the client’s room to administer medication. While looking out the window at the trees, the client remarks, "That school across the street has creatures in it that are waiting for me." Which of the following is the most appropriate response by the nurse? You Selected: • “How do you feel when you see the creatures?” Correct response: • “How do you feel when you see the creatures?” Explanation: Remediation: Question 9 See full question A nurse caring for a client with schizophrenia goes into the client’s room to administer medication. While looking out the window at the trees, the client remarks, "That school across the street has creatures in it that are waiting for me." Which of the following is the most appropriate response by the nurse? You Selected: • “How do you feel when you see the creatures?” Correct response: • “How do you feel when you see the creatures?” Explanation: Remediation: Question 10 See full question The nurse is planning care for a client admitted for vascular dementia. Which action is most appropriate in assisting the client with activities of daily living? You Selected: • Document all activities the nurse expects the client to complete during the shift. Correct response: • Encourage client to complete as many activities as possible, and provide ample time to complete them. Question 1 See full question A client with a diagnosis of schizophrenia is admitted to the inpatient unit of the mental health center. He's shouting that the government of France is trying to assassinate him. Which response is most appropriate? You Selected: • "A foreign government is trying to kill you? Please tell me more about it." Correct response: • "I don't see evidence that a foreign government or anyone else is trying to hurt you. You must feel frightened by this." Explanation: Remediation: Question 2 See full question Benztropine is used to treat the extrapyramidal effects induced by antipsychotics. This drug exerts its effect by: You Selected: • blocking cholinergic activity in the central nervous system (CNS). Correct response: • blocking cholinergic activity in the central nervous system (CNS). Explanation: Remediation: Question 3 See full question A client with schizophrenia displays a lack of interest in activities, reduced affect, and poor ability to perform activities of daily living. What term would be used to describe this clustering of symptoms? You Selected: • Negative symptoms Correct response: • Negative symptoms Explanation: Remediation: Question 4 See full question A client diagnosed with borderline personality disorder has self-inflicted cuts on her arms. The nurse is assessing the client for the risk of suicide. What should the nurse ask the client first? You Selected: • if she has a suicide plan Correct response: • if she has a suicide plan Explanation: Remediation: Question 5 See full question Question 1See full question An agitated and incoherent client comes to the emergency department with complaints of visual and auditory hallucinations. The history reveals that this client was hospitalized for schizophrenia from ages 20 to 21. The physician orders haloperidol, 5 mg I.M. The nurse understands that this drug is used in this client to treat: You Selected: • dyskinesia. Correct response: • psychosis. Explanation: Remediation: Question 2See full question A client with a diagnosis of schizophrenia is admitted to the psychiatric hospital in a catatonic state. During the physical examination, the client's arm remains outstretched after the nurse obtains his pulse and blood pressure readings, and the nurse must reposition his arm. This client is exhibiting: You Selected: • suggestibility. Correct response: • waxy flexibility. Explanation: Remediation: Question 3See full question A client with schizophrenia tells the nurse, "My intestines are rotted from the worms chewing on them." This statement indicates a: You Selected: • delusion of grandeur. Correct response: • somatic delusion. Explanation: Remediation: Question 4See full question 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? You Selected: • Dantrolene Correct response: • Benztropine Explanation: Remediation: Question 5See full question A nurse is caring for a client receiving a dopamine receptor agonist for treatment of extrapyramidal symptoms caused by antipsychotic medications. What evaluation would indicate a therapeutic response to this drug? You Selected: • Client exhibits akathisia only while sitting. Correct response: • Client experiences a decrease in dystonia. Explanation: Remediation: Question 6See full question A client diagnosed with schizophrenia gained 50 lb (22.7 kg) in 6 months while taking olanzapine. After a prescription change from olanzapine to ziprasidone, the client tells the nurse, “I do not want to take this ziprasidone either. I cannot gain any more weight.” Which response by the nurse is most appropriate for this client? You Selected: • "You can take it just before bedtime, so you will not need a snack." Correct response: • "Ziprasidone causes less weight gain than the other atypical antipsychotics." Explanation: Remediation: Question 7See full question At an outpatient visit 3 months after discharge from the hospital, a client says he has stopped his olanzapine even though it controls his symptoms of schizophrenia better than other medications. "I have gained 20 lb (9.1 kg) already. I cannot stand anymore." Which response by the nurse is mostappropriate? You Selected: • "Your weight gain will level off if you stay on the medication 3 more months." Correct response: • "I can help you with a diet and exercise plan to keep your weight down." Explanation: Remediation: Question 8See full question A client with schizophrenia comes to the outpatient mental health clinic 5 days after being discharged from the hospital. The client was given a 1-week supply of clozapine. The client tells the nurse that she has too much saliva and frequently needs to spit. The nurse interprets the client’s statement as being consistent with which factor? You Selected: • unusual reaction to clozapine Explanation: Remediation: Question 14See full question A client whose symptoms of schizophrenia are under control with olanzapine, and who is functioning at home and in her part-time employment, states that she is very concerned about her 20-lb (9.1- kg) weight gain since she started taking the medication 6 months ago. The nurse should: You Selected: • suggest that the client talk with her healthcare provider about changing to another antipsychotic. Correct response: • discuss nutrition, daily diet, and exercise with the client. Explanation: Remediation: Question 15See full question A nurse is caring for a client with schizoaffective disorder. The client is currently experiencing auditory hallucinations. Which of the following nursing actions would take first priority for this client? You Selected: • Engaging the client in reality-based conversations Correct response: • Engaging the client in reality-based conversations Explanation: Remediation: Question 16See full question A client is sitting in the dining area and laughing out loud, shaking her head, and whispering behind her hand. Suddenly the client begins banging her head against the wall. Which of the following interventions by the nurse is most appropriate? You Selected: • Calmly walk over to the client and say, "Tell me what's going on." Correct response: • Calmly walk over to the client and say, "Tell me what's going on." Explanation: Remediation: Question 17See full question A nurse is caring for a client who is in a catatonic state due to schizophrenia. Which of the following nursing interventions would be most important in the care of this client? You Selected: • Assess the level of family functioning and availability of support systems. Correct response: • Predict and fulfill client needs until the client is more active. Explanation: Remediation: Question 18See full question A client experiencing a schizophrenic episode is hospitalized. The client is attempting to hit and bite the staff. When the nurse phones the primary care provider for orders to help calm the client, the nurse anticipates what medication is likely to be ordered? You Selected: • Lithium carbonate Correct response: • Haloperidol Explanation: Remediation: Question 19See full question The nurse is reviewing laboratory values of a client receiving clozapine. Which of the following laboratory values does the nurse immediately report to the health care provider (HCP)? You Selected: • WBC of 3,500 Correct response: • WBC of 3,500 Explanation: Remediation: Question 20See full question A nurse is working with a schizophrenic client who suddenly begins experiencing auditory hallucinations. Which interactions are appropriate at this time? Select all that apply. You Selected: • Ask the client if he/she has recently taken any drugs or alcohol. • Tell the client, “I’d like to spend time with you to discuss your hallucinations. Is that okay with you?” • Ask the client, “What are you experiencing right now?” Correct response: • Ask the client, “What are you experiencing right now?” • Encourage the client to relate the history of the hallucinations. • Tell the client, “I’d like to spend time with you to discuss your hallucinations. Is that okay with you?” • Ask the client if he/she has recently taken any drugs or alcohol. • "You had to wait. Can we talk about how this is making you feel right now?" Correct response: • "You had to wait. Can we talk about how this is making you feel right now?" Explanation: Remediation: Question 5See full question A client with persistent, severe schizophrenia has been treated with phenothiazines for the past 17 years. Now the client's speech is garbled as a result of drug-induced rhythmic tongue protrusion. What is another name for this extrapyramidal symptom? You Selected: • Tardive dyskinesia Correct response: • Tardive dyskinesia Explanation: Remediation: Question 6 See full question A nurse is planning care for a client with a diagnosis of schizophrenia who has been admitted to the psychiatric unit. Which nursing diagnosis should receive the highest priority? You Selected: • Risk for other-directed violence Correct response: • Risk for other-directed violence Explanatio n: Remediati on: Question 7 See full question A nurse is teaching a psychiatric client about his ordered drugs, chlorpromazine and benztropine. What evaluation would indicate a therapeutic response to these drugs? You Selected: • The client is experiencing less psychosis and a decrease in extrapyramidal symptoms. Correct response: • The client is experiencing less psychosis and a decrease in extrapyramidal symptoms. Explanation: Remediation: Question 8See full question Benztropine is used to treat the extrapyramidal effects induced by antipsychotics. This drug exerts its effect by: You Selected: • blocking cholinergic activity in the central nervous system (CNS). Correct response: • blocking cholinergic activity in the central nervous system (CNS). Explanation: Remediation: Question 9See full question A client who's taking antipsychotic medication develops a very high temperature, severe muscle rigidity, tachycardia, and rapid deterioration in mental status. What complication of antipsychotic therapy does the nurse suspect? You Selected: • Agranulocytosis Correct response: • Neuroleptic malignant syndrome Explanation: Remediation: Question 10 See full question During the assessment stage, a client with schizophrenia leaves his arm in the air after the nurse has taken his blood pressure. His action shows evidence of: You Selected: • waxy flexibility. Correct response: • waxy flexibility. Explanation: Remediation: Question 11 See full question A client with schizophrenia displays a lack of interest in activities, reduced affect, and poor ability to perform activities of daily living. What term would be used to describe this clustering of symptoms? You Selected: • Negative symptoms Correct response: • Negative symptoms Explanation: Remediation: Question 12 See full question Which concept is most important for a nurse to communicate to a client preparing to sign an informed consent for electroconvulsive therapy (ECT)? You Selected: • "You may experience a time of confusion after the treatment." Correct response: • Ask about the marital problems leading to the divorce. • Interview the client about her current needs and situation. • Assess the client’s risk for harm to self and others. • Obtain the name of her ex-husband’s case manager. Correct response: • Assess the client’s risk for harm to self and others. • Interview the client about her current needs and situation. • Obtain the name of her ex-husband’s case manager. • Ask about the marital problems leading to the divorce. Explanation: Remediation: Question 18 See full question A client is admitted to the psychiatric unit exhibiting extreme agitation, disorientation, and incoherence of speech with frantic and aimless physical activity and grandiose delusions. Which of the following would the highest priority goal in planning nursing interventions? You Selected: • The client will show no self-harm or harm to staff. Correct response: • The client will show no self-harm or harm to staff. Explanation: Remediation: Question 19 See full question The nurse recognizes the client in the emergency department from a picture in the local paper. The client has recently received a major scholarship for high academic achievement. The client tells the nurse that he hears voices that tell him he is worthless. He has tried to kill himself. What statement is the most appropriate for the nurse to use first when attempting to establish a therapeutic relationship? You Selected: • "I am sorry this is happening to you." Correct response: • "I am sorry this is happening to you." Explanation: Remediation: Question 20 See full question A client has been admitted to the emergency department. The client’s family tells the nurse that the client has suddenly become lethargic and is “not making sense.” The client has not had anything to eat or drink for the last 8 hours. The nurse further assesses the client using the Confusion Assessment Method (CAM). The client’s responses to questions are rambling, and the client is not able to focus clearly to answer the nurse’s questions. Based on these findings, the nurse should report that the client has: You Selected: • dementia Correct response: • delirium Explanation: Question 3 See full question A client with a diagnosis of borderline personality disorder is admitted to the psychiatric unit. The nurse expects the assessment to reveal: You Selected: • unpredictable behavior and intense interpersonal relationships. Correct response: • unpredictable behavior and intense interpersonal relationships. Explanation: Remediation: Question 4 See full question A client with a tentative diagnosis of psychosis is admitted to the psychiatric unit. A physician orders the phenothiazine thioridazine 50 mg by mouth three times per day. Phenothiazines differ from central nervous system (CNS) depressants in their sedative effects by producing: You Selected: • a calming effect from which the client is easily aroused. Correct response: • a calming effect from which the client is easily aroused. Explanation: Remediation: Question 5 See full question A client begins clozapine therapy after several other antipsychotic agents fail to relieve her psychotic symptoms. The nurse instructs her to return for weekly white blood cell (WBC) counts to assess for which adverse reaction? You Selected: • Granulocytopenia Correct response: • Granulocytopenia Explanation: Remediation: Question 6 See full question A client is unable to get out of bed and get dressed unless a nurse prompts every step. This is an example of which behavior? You Selected: • Avolition Correct response: • Avolition Explanation: Question 7 See full question One of the advantages of the antipsychotic medication APO-risperidone is: Explanation: Remediation: Question 4 See full question The client with histrionic personality disorder is melodramatic and responds to others and situations in an exaggerated manner. The nurse should recommend which activity for this client? You Selected: • music group Correct response: • role-playing Explanation: Question 5 See full question A client reports having thoughts of being followed by foreign agents who are after his secret papers. Which response by the nurse is most appropriate when responding to the client's disturbed thought process? You Selected: • "I think these thoughts are frightening to you." Correct response: • "I think these thoughts are frightening to you." Explanation: Remediation: Question 6 See full question The director of an outpatient rehab program tells the nurse that the client with schizophrenia had done well for 6 months until last week, when a new person started the program. This new person worked faster than the client did and took his place as leader of the group. Based on this information, which intervention is most appropriate? You Selected: • Make an appointment to meet the client at the mental health center, and ask him about the situation. Correct response: • Make an appointment to meet the client at the mental health center, and ask him about the situation. Explanation: Remediation: Question 7 See full question The client thinks he is being followed by foreign agents who are after secret papers in his briefcase. What thought process does this indicate? You Selected: • delusion of persecution Correct response: • delusion of persecution Explanation: Remediation: Question 8 See full question A client with a chronic mental illness has worked as a hotel maid for the past 3 years. She tells the nurse she is thinking of quitting her job because “voices on television are talking about me.” The nurse should first: You Selected: • arrange for the client to be admitted to a psychiatric hospital for a short stay. Correct response: • obtain information about the client's medication compliance. Explanation: Remediation: Question 9 See full question A nurse is caring for a client with schizoaffective disorder. The client is currently experiencing auditory hallucinations. Which of the following nursing actions would take first priority for this client? You Selected: • Engaging the client in reality-based conversations Correct response: • Engaging the client in reality-based conversations Explanation: Remediation: Question 10 See full question A client with schizophrenia states “I can’t stay here. I have to get away.” The nurse observes that the client is very agitated. What should be the nurse’s first action? You Selected: • Allow the client to express feelings Correct response: • Approach the client in a calm, nonthreatening manner Question 1See full question A client with schizophrenia is admitted to the psychiatric unit of a local hospital. During the next several days, the client is seen laughing, yelling, and talking to himself. This behavior is characteristic of: You Selected: • hallucination. Correct response: • hallucination. Explanation: Remediation: Question 2See full question A client with schizophrenia is admitted to the psychiatric unit of a hospital. Nursing assessment should include careful observation of the client's: You Selected: • thinking, perceiving, and decision-making skills. Correct response: • thinking, perceiving, and decision-making skills. Explanation: Remediation: Question 3See full question A client with a tentative diagnosis of psychosis is admitted to the psychiatric unit. A physician orders the phenothiazine thioridazine 50 mg by mouth • Benztropine Explanation: Remediation: Question 9See full question Teaching for women of childbearing years who are receiving antipsychotic medications includes which statement? You Selected: • Continue previous contraceptive use even if you're experiencing amenorrhea. Correct response: • Continue previous contraceptive use even if you're experiencing amenorrhea. Explanation: Question 10 See full question A client with a diagnosis of antisocial personality disorder has a potential for violence and aggressive behavior. Which short-term client outcome is most appropriate for the nurse to include in the plan of care? You Selected: • Discuss feelings of anger with staff. Correct response: • Discuss feelings of anger with staff. Explanation: Remediation: Question 11 See full question The client diagnosed with borderline personality disorder who is to be discharged soon threatens to "do something" to herself if discharged. The nurse should first: You Selected: • ask a family member to stay with the client at home temporarily. Correct response: • discuss the meaning of the client's statement with her. Explanation: Remediation: Question 12 See full question The parent of a young adult client diagnosed with schizophrenia is asking questions about his son's antipsychotic medication, ziprasidone. Which statement by the parent reflects a need for further teaching? You Selected: • "The ziprasidone should help him be more motivated and less withdrawn." Correct response: • "I should give him benztropine to help prevent constipation from the ziprasidone." Explanation: Remediation: Question 13 See full question After 3 days of taking haloperidol , the client shows an inability to sit still, is restless and fidgety, and paces around the unit. The client is showing signs of which extrapyramidal adverse reactions? You Selected: • akathisia Correct response: • akathisia Explanation: Remediation: Question 14 See full question A client with a chronic mental illness has worked as a hotel maid for the past 3 years. She tells the nurse she is thinking of quitting her job because “voices on television are talking about me.” The nurse should first: You Selected: • obtain information about the client's medication compliance. Correct response: • obtain information about the client's medication compliance. Explanation: Remediation: Question 15 See full question When assessing a hospitalized client diagnosed with Major Depression and Borderline Personality Disorder, the nurse should ask the client about which of the following first? You Selected: • Suicidal thoughts. Correct response: • Suicidal thoughts. Explanation: Remediation: Question 16 See full question The nurse is reviewing laboratory values of a client receiving clozapine. Which laboratory value should the nurse report to the health care provider (HCP)? You Selected: • sodium level of 136 mEq/L (136 mmol/L) Correct response: • WBC of 3,500/µL (3.5 X 109/L) Explanatio n: Remediati on: Question 17 See full question Remediation: Question 3 See full question Clozapine therapy has been initiated for a client with schizophrenia who has been unresponsive to other antipsychotics. The client states, "Why do I have to have a blood test every week?" Which response by the nurse would be most appropriate? You Selected: • "Weekly blood tests are necessary to determine safe dosage and to monitor the effect of the medication on the blood." Correct response: • "Weekly blood tests are necessary to determine safe dosage and to monitor the effect of the medication on the blood." Explanation: Remediation: Question 4 See full question When caring for a client receiving haloperidol, the nurse should assess for which problem? You Selected: • extrapyramidal symptoms Correct response: • extrapyramidal symptoms Explanation: Remediation: Question 5 See full question A client with bipolar disorder, manic phase, begins to swear at the nurse when reminded to limit telephone calls to 10 minutes. The nurse should respond by saying: You Selected: • "You know better than to use that language." Correct response: • "Stop! Swearing is not appropriate behavior." Explanation: Remediation: Question 6 See full question A client is admitted to the psychiatric unit exhibiting extreme agitation, disorientation, and incoherence of speech with frantic and aimless physical activity and grandiose delusions. Which of the following would the highest priority goal in planning nursing interventions? You Selected: • The client will show no self-harm or harm to staff. Correct response: • The client will show no self-harm or harm to staff. Explanation: Remediation: Question 7 See full question A client is sitting in the dining area and laughing out loud, shaking her head, and whispering behind her hand. Suddenly the client begins banging her head against the wall. Which of the following interventions by the nurse is most appropriate? You Selected: • Calmly walk over to the client and say, "Tell me what's going on." Correct response: • Calmly walk over to the client and say, "Tell me what's going on." Explanation: Remediation: Question 8 See full question The parents of a teenager recently diagnosed with schizophrenia ask the nurse about whether their other children will be susceptible as well. The nurse explains that schizophrenia is caused by: You Selected: • a combination of biological, psychologic, and environmental factors. Correct response: • a combination of biological, psychologic, and environmental factors. Explanation: Remediation: Question 9 See full question A client who was prescribed clozapine 2 months ago arrives in the clinic and informs the nurse that he has 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 of the following does the nurse suspect may be occurring with this client? You Selected: • Agranulocytosis Correct response: • Agranulocytosis Explanation: Remediation: Question 10 See full question What should be charted by the nurse when the client has an involuntary commitment or formal admission status? You Selected: • The name of the physician officially signing the certificates should be charted. Correct response: • The client’s receipt of information about status and rights should be charted. Question 1 See full question A client with schizophrenia and delusions tells a nurse, "There is a man wearing a red coat who's out to get me." The client exhibits increasing anxiety when focusing on the delusion. Which response by the nurse is appropriate? You Selected: • "This subject seems to be troubling you. Let's walk to the activity room." Correct response: • "This subject seems to be troubling you. Let's walk to the activity room." Explanation: Remediation: Question 2 See full question A client who takes neuroleptic medication for treatment of chronic schizophrenia is admitted to the psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, and diaphoresis. Which life- threatening reaction do these findings suggest? You Selected: • Neuroleptic malignant syndrome Question 9 See full question The nurse is caring for a hospitalized client who has a disorder of the amygdala. Which of symptoms can the nurse anticipate that the client will have? You Selected: • difficulties with speech Correct response: • impulsive acts of aggression Explanation: Question 10 See full question The nurse is planning the care of a client with schizophrenia. The nurse understands that the client will need the most extensive laboratory monitoring regiment if which medication is prescribed? You Selected: • clozapine Correct response: • clozapine Question 1 See full question A man is brought to the hospital by his wife, who states that he has refused all meals for the past week and accused her of trying to poison him. During the initial interview, the client's speech, only partly comprehensible, reveals that his thoughts are controlled by delusions that he is possessed by the devil. A physician diagnoses paranoid schizophrenia. Schizophrenia is best described as a disorder characterized by: You Selected: • preoccupation with persecutory delusions, anxiety, anger, and potential for violence. Correct response: • preoccupation with persecutory delusions, anxiety, anger, and potential for violence. Explanation: Remediation: Question 2 See full question When discharging a client after treatment for a dystonic reaction, an emergency department nurse must ensure that the client understands: You Selected: • the client must take benztropine as ordered to prevent a return of symptoms. Correct response: • the client must take benztropine as ordered to prevent a return of symptoms. Explanation: Remediation: Question 3 See full question A client with schizophrenia believes his room is bugged by the Central Intelligence Agency (Canadian Security Intelligence Service) and that his roommate is a foreign spy. The client has never had a romantic relationship, has no contact with family members, and has not been employed in the past 14 years. Based on Erikson's theories, the nurse should recognize that this client is in which stage of psychosocial development? You Selected: • Integrity versus despair Correct response: • Trust versus mistrust Explanation: Question 4 See full question A nurse is caring for a client who experiences false sensory perceptions that have no basis in reality. These perceptions are known as: You Selected: • delusions. Correct response: • hallucinations. Explanation: Remediation: Question 5 See full question A nurse is aware that antipsychotic medications may cause: You Selected: • lower seizure threshold. Correct response: • lower seizure threshold. Explanation: Question 6 See full question A client in a catatonic state is admitted to the inpatient unit. The client is emaciated, stares blankly into space, and does not respond to verbal or tactile stimuli. In formulating nursing care interventions, the nurse should give priority to: You Selected: • providing a safe and supportive environment for the client. Correct response: • observing and evaluating the client's nutritional needs. Explanation: Remediation: Question 7 See full question A client diagnosed with paranoid personality disorder is hospitalized for physically threatening his wife because he suspects her of having an affair with a coworker. What approach should the nurse employ with this client? You Selected: • matter-of-fact Correct response: • matter-of-fact Explanation: Question 8 See full question The guardian of a client diagnosed with schizophrenia indicates to the nurse a concern that the client is at risk for suicide. Which question to the client would the nurse utilize to determine the seriousness of the suicidal idealization? You Selected: • “Are you planning on hurting yourself?” Correct response: • “Are you planning on hurting yourself?” Explanation: Remediation: Question 9 See full question You Selected: • Sitting up for a few minutes before standing to minimize orthostatic hypotension Correct response: • Sitting up for a few minutes before standing to minimize orthostatic hypotension Explanation: Remediation: Question 6See full question A nurse is providing care to a client with schizophrenia who exhibits extreme negativism. To help the client meet his basic needs, the nurse should: You Selected: • tell the client specifically and concisely what needs to be done. Correct response: • tell the client specifically and concisely what needs to be done. Explanation: Remediation: Question 7See full question During an extremely busy shift on the psychiatric unit, a newly graduated nurse approaches the charge nurse and states, "I'm having a hard time taking care of mentally ill people. What can I do to handle this stress?" The charge nurse's best response is: You Selected: • "Maybe we could schedule a time to discuss this further." Correct response: • "Maybe we could schedule a time to discuss this further." Explanation: Remediation: Question 8See full question The nurse observes that a client on a psychiatric unit is looking around the room with eyes darting to a chair in the corner. The client grimaces and then states, “Bastard,” under his breath. Which nursing action is most appropriate? You Selected: • Approach the client to interrupt the hallucinations. Correct response: • Approach the client to interrupt the hallucinations. Explanation: Remediation: Question 9See full question A client with chronic schizophrenia is admitted to the hospital on an emergency detention. The client states to the nurse, "I didn't do anything wrong. I was just carrying out the orders God gave me to paint an X on the door of all sinners." Several hours after being admitted, the client wants to leave the hospital. In addition to explaining that the staff is concerned about the client's health and safety, which of the following should the nurse tell the client? You Selected: • "The law requires you to stay here until you are well." Correct response: • "The court has mandated that you undergo a 72-hour evaluation." Explanation: Remediation: Question 10See full question The nurse is caring for a client on the psychiatric unit. The client states, “The voices are bothering me. They are yelling and telling me stuff. They are really bad.” Which of the following responses by the nurse would be most appropriate? You Selected: • “I do not hear any voices. What are you hearing?” Correct response: • “I do not hear any voices. What are you hearing?” Explanation: Remediation: Question 10 See full question The nurse is planning care for a client who has been experiencing a manic episode for 6 days and is unable to sit still long enough to eat meals. Which choice will best meet the client’s nutritional needs at this time? You Selected: • Offer a peanut butter sandwich. Correct response: • Offer a peanut butter sandwich. Question 1 See full question A client with schizophrenia hears a voice telling him that he is evil and must die. The nurse understands that this client is experiencing: You Selected: • a hallucination. Correct response: • a hallucination. Explanation: Remediation: Question 2 See full question A client with persistent, severe schizophrenia has been treated with phenothiazines for the past 17 years. Now the client's speech is garbled as a result of drug-induced rhythmic tongue protrusion. What is another name for this extrapyramidal symptom? Explanation: Remediation: Question 9 See full question The nurse recognizes the client in the emergency department from a picture in the local paper. The client has recently received a major scholarship for high academic achievement. The client tells the nurse that he hears voices that tell him he is worthless. He has tried to kill himself. What statement is the most appropriate for the nurse to use first when attempting to establish a therapeutic relationship? You Selected: • "I am sorry this is happening to you." Correct response: • "I am sorry this is happening to you." Explanation: Remediation: Question 10 See full question A client, diagnosed with Alzheimer’s disease, is a new resident in a long-term care facility. The client has difficulty finding his/her 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. You Selected: • Provide verbal cueing as to where the client’s room is located. • Assign the client to a room close to the nursing station for closer monitoring. • Ensure that the client has prescribed hearing aids and glasses on throughout the day. Correct response: • 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. Question 1 See full question A client tells a nurse that people from Mars are going to invade the Earth. Which response by the nurse would be therapeutic? You Selected: • "That must be frightening to you. Can you tell me how you feel about it?" Correct response: • "That must be frightening to you. Can you tell me how you feel about it?" Explanation: Remediation: Question 2 See full question Which group of characteristics should a nurse expect to see in the client with schizophrenia? You Selected: • Loose associations, grandiose delusions, and auditory hallucinations Correct response: • Loose associations, grandiose delusions, and auditory hallucinations Explanation: Remediation: Question 3 See full question A client is admitted to the psychiatric unit with acute onset of schizophrenia. His physician orders the phenothiazine chlorpromazine, 100 mg by mouth four times per day. Before administering the drug, a nurse reviews the client's medication history. Concomitant use of which drug is likely to increase the risk of extrapyramidal effects? You Selected: • Guanethidine Correct response: • Droperidol Explanation: Remediation: Question 4 See full question A client with a tentative diagnosis of psychosis is admitted to the psychiatric unit. A physician orders the phenothiazine thioridazine 50 mg by mouth three times per day. Phenothiazines differ from central nervous system (CNS) depressants in their sedative effects by producing: You Selected: • a calming effect from which the client is easily aroused. Correct response: • a calming effect from which the client is easily aroused. Explanation: Remediation: Question 5 See full question Important teaching for a client receiving risperidone should include advising the client to: You Selected: • be sure to take the drug with a meal because it can severely irritate the stomach. Correct response: • notify the physician if he notices an increase in bruising. Explanation: Remediation: Question 6 See full question A client with bipolar disorder, manic phase, begins to swear at the nurse when reminded to limit telephone calls to 10 minutes. The nurse should respond by saying: You Selected: • "Stop! Swearing is not appropriate behavior." Correct response: • "Stop! Swearing is not appropriate behavior." Explanation: Remediation: Question 7 See full question The client thinks he is being followed by foreign agents who are after secret papers in his briefcase. What thought process does this indicate? You Selected: • delusion of persecution Correct response: • delusion of persecution Explanation: Remediation: • thinking, perceiving, and decision-making skills. Explanation: Remediation: Question 5 See full question A nurse knows that a physician has ordered the liquid form of the drug chlorpromazine rather than the tablet form because the liquid: You Selected: • has a more predictable onset of action. Correct response: • has a more predictable onset of action. Explanation: Remediation: Question 6 See full question A client has a history of schizophrenia. Because he has a history of noncompliance with antipsychotic therapy, he will receive fluphenazine decanoate injections every 4 weeks. Before discharge, what should the nurse include in her teaching plan? You Selected: • Sitting up for a few minutes before standing to minimize orthostatic hypotension Correct response: • Sitting up for a few minutes before standing to minimize orthostatic hypotension Explanation: Remediation: Question 7 See full question Propranolol is used in the mental health setting to: You Selected: • treat antipsychotic-induced akathisia and anxiety. Correct response: • treat antipsychotic-induced akathisia and anxiety. Explanation: Remediation: Question 8 See full question During the assessment stage, a client with schizophrenia leaves his arm in the air after the nurse has taken his blood pressure. His action shows evidence of: You Selected: • waxy flexibility. Correct response: • waxy flexibility. Explanation: Remediation: Question 9 See full question After working multiple shifts in the psychiatric intensive care unit, a nurse recognizes that she's becoming more distant and, at times, even irritable. The best action for the nurse to take would be to: You Selected: • talk with the charge nurse and seek support from her peers on the unit. Correct response: • talk with the charge nurse and seek support from her peers on the unit. Explanation: Remediation: Question 10 See full question A client admitted with a diagnosis of schizoaffective disorder, manic phase, who is currently taking fluoxetine, valproic acid, and olanzapine as prescribed, has had an increase in manic symptoms in the past week. The health care provider (HCP) prescribes a valproic acid blood level to be drawn at once. What does the nurse understand is the rationale for this prescription? You Selected: • All clients taking valproic acid need periodic valproic acid levels drawn. Correct response: • A decrease in the level of valproic acid could explain the increase in manic symptoms. Question 1 See full question During the initial interview, a client with schizophrenia suddenly turns to the empty chair beside him and whispers, "Now just leave. I told you to stay home. There isn't enough work here for both of us!" What is the nurse's best initial response? You Selected: • "When people are under stress, they may see things or hear things that others don't. Is that what just happened?" Correct response: • "When people are under stress, they may see things or hear things that others don't. Is that what just happened?" Explanation: Remediation: Question 2 See full question Which information is important for a nurse to include in a teaching plan for a client with schizophrenia who is taking clozapine? You Selected: • Report a sore throat or fever to the physician immediately. Correct response: • Report a sore throat or fever to the physician immediately. Explanation: Remediation: Question 3 See full question For the client with catatonic behaviors, which outcome would indicate a medication has been most effective in improving long-term behavior? You Selected: • The client responds to verbal directions to eat. Correct response: • The client initiates simple activities without directions. Explanation: Remediation: Question 4 See full question One of the clients in group with a dual diagnosis of chronic schizophrenia and alcohol abuse states, “I am not going to take medicine every day.” Which response by the nurse would be most appropriate? You Selected: • “Would anyone in group like to discuss this?” devil. A physician diagnoses paranoid schizophrenia. Schizophrenia is best described as a disorder characterized by: You Selected: • preoccupation with persecutory delusions, anxiety, anger, and potential for violence. Correct response: • preoccupation with persecutory delusions, anxiety, anger, and potential for violence. Explanation: Remediation: Question 3See full question When discharging a client after treatment for a dystonic reaction, an emergency department nurse must ensure that the client understands: You Selected: • the client must take benztropine as ordered to prevent a return of symptoms. Correct response: • the client must take benztropine as ordered to prevent a return of symptoms. Explanation: Remediation: Question 4See full question Which effects do most antipsychotic medications exert on the central nervous system (CNS)? You Selected: • They depress the CNS by blocking the postsynaptic transmission of dopamine, serotonin, and norepinephrine. Correct response: • They depress the CNS by blocking the postsynaptic transmission of dopamine, serotonin, and norepinephrine. Explanation: Remediation: Question 5See full question One of the advantages of the antipsychotic medication APO- risperidone is: You Selected: • a lower incidence of extrapyramidal effects. Correct response: • a lower incidence of extrapyramidal effects. Explanation: Remediation: Question 6See full question A client diagnosed with paranoid personality disorder is hospitalized for physically threatening his wife because he suspects her of having an affair with a coworker. What approach should the nurse employ with this client? You Selected: • matter-of-fact Correct response: • matter-of-fact Explanation: Question 7See full question The wife of a client admitted for treatment of newly diagnosed paranoid schizophrenia visits 2 days after her husband’s admission and states to the nurse, “Why is he not eating? He is still talking about his food being poisoned.” Which appraisal by the nurse is most accurate? You Selected: • Her expectations of her husband are realistic. Correct response: • Education about her husband's medications is needed. Explanation: Remediation: Question 8See full question A 25-year-old client diagnosed with chronic schizophrenia states, "I stopped my medications a week ago. I was just tired of not being able to drink with my friends. Besides, I feel fine without them." Which response by the nurse is most appropriate? You Selected: • "I hear how difficult it must be to live with the changes caused by your illness." Correct response: • "I hear how difficult it must be to live with the changes caused by your illness." Explanation: Remediation: Question 9See full question A client with antisocial personality disorder tells the nurse, “I punched the guy out because he deserved it, and then the cops arrested me.” Which response would be most helpful to the client? You Selected: • "It is wrong to punch others." Correct response: • "If you punch people out, you will get into trouble." Explanation: Remediation: Question 10 See full question 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? You Selected: • "She may have stopped taking her medications. I will check on her." Explanation: Remediation: Question 5 See full question The nurse assesses a client to be at risk for self-mutilation and implements a safety contract with the client. Which client behavior indicates that the contract is working? You Selected: • The client notifies staff when anxiety is increasing. Correct response: • The client notifies staff when anxiety is increasing. Explanation: Remediation: Question 6 See full question A client claims to have a "special mission from God". The nurse incorporates this religious delusion of grandeur into the client's plan of care based on the understanding that the primary purpose of such a delusion is to provide: You Selected: • self-esteem. Correct response: • self-esteem. Explanation: Remediation: Question 7 See full question The nurse is performing an assessment of a client admitted to the behavioral health unit with schizophrenia. Which of the following behaviors by the client would the nurse document as positive symptoms? Select all that apply. You Selected: • Client states, “I am the King of England!” • Client is copying the movements of the client sitting next to them. • Client states, “Do you see all of the rats crawling on the floor? Kill them!” Correct response: • Client states, “I am the King of England!” • Client is copying the movements of the client sitting next to them. • Client states, “Do you see all of the rats crawling on the floor? Kill them!” Explanation: Remediation: Question 8 See full question A client who was prescribed clozapine 2 months ago arrives in the clinic and informs the nurse that he has 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 of the following does the nurse suspect may be occurring with this client? You Selected: • Agranulocytosis Correct response: • Agranulocytosis Explanation: Remediation: Question 9 See full question The nurse recognizes the client in the emergency department from a picture in the local paper. The client has recently received a major scholarship for high academic achievement. The client tells the nurse that he hears voices that tell him he is worthless. He has tried to kill himself. What statement is the most appropriate for the nurse to use first when attempting to establish a therapeutic relationship? You Selected: • "I am sorry this is happening to you." Correct response: • "I am sorry this is happening to you." Explanation: Remediation: Question 10 See full question The nurse is caring for a hospitalized client who has a disorder of the amygdala. Which of symptoms can the nurse anticipate that the client will have? You Selected: • impulsive acts of aggression Correct response: • impulsive acts of aggression Question 1 See full question 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? You Selected: • Apply a sunscreen before exposure to the sun. Correct response: • Apply a sunscreen before exposure to the sun. Explanation: Remediation: Question 2 See full question A client is admitted with a diagnosis of schizotypal personality disorder. Which signs would this client exhibit during social situations? You Selected: • Emotional affect Correct response: • Paranoid thoughts Explanation: Question 3 See full question The nurse observes that a client on a psychiatric unit is looking around the room with eyes darting to a chair in the corner. The client grimaces and then states, “Bastard,” under his breath. Which nursing action is most appropriate? You Selected: • Approach the client to interrupt the hallucinations. Correct response: • Approach the client to interrupt the hallucinations. Explanation: Remediation: