Schizophrenia, Other Psychoses, and Cognitive Disorders NCLEX Questions with Rationale

NCLEX Schizophrenia, Other Psychoses, and Cognitive Disorders Questions

Schizophrenia, Other Psychoses, and Cognitive Disorders NCLEX Practice Questions

Question 1.    
A newly admitted client describes her mission in life as one of saving her son by eliminating the “provocative sluts” of the world. There are several attractive young women on the unit. What should the nurse do first?
(a) Ask the client for her definition of “provocative sluts.”
(b) Discuss dress code with all clients at the next group meeting.
(c) Have the client discuss her concerns in the next group session.
(d) Ask the client to inform the staff if she has negative thoughts about other clients.
Answer:
(d) Ask the client to inform the staff if she has negative thoughts about other clients.

Explanation:
It is critical for the nurse to ensure the safety of others by knowing who the client might think needs elimination. Asking the client to explain what she means and discussing her concerns at the group session are possible interventions for later in the client’s hospital stay. Wearing appropriate clothing while hospitalized is generally a unit expectation for all clients.

Question 2.
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?
(a) “With whom do you want to do things?”
(b) “What activities did you enjoy in the past?”
(c) “What kind of transportation do you use?”
(d) “How much money can you spend?”
 Answer:
 (b) “What activities did you enjoy in the past?”
 
Explanation:
Knowing the client’s interests is the best place to begin to help the client resocialize. Knowing with whom the client wishes to socialize, what transportation she has, or how much spending money she has may be relevant questions, but these questions should be asked after the question concerning what activities the client enjoyed in the past.
 
Question 3.    
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?
(a) “You have a lot to live for.”
(b) “The voices are not real.”
(c) “I’m sorry this is happening to you.”
(d) “Would you like me to call your parents?”
Answer:
(c) “I’m sorry this is happening to you.”

Explanation:
Demonstrating empathy is an effective means of beginning an effective therapeutic relationship. Challenging the client’s beliefs or thoughts is not the most effective in establishing a trusting relationship. Determining what supports are needed is done after an initial assessment.

Question 4.    
A client who is neatly dressed and clutching a leather briefcase tightly in his arms scans the adult inpatient unit on his arrival at the hospital and backs away from the window. The client requests that the nurse move away from the window. The nurse recognizes that doing as the client requested is contraindicated for which reason?
(a) The action will make the client feel that the nurse is humoring him.
(b) The action indicates nonverbal agreement with the client’s false ideas.
(c) The client will then think that he will have his way when he wishes.
(d) The nurse will be demonstrating a lack of composure over the situation. 
Answer:
(b) The action indicates nonverbal agreement with the client’s false ideas.

Explanation:
The nurse’s nonverbal behavior, moving away from the window as the client requests, indicates agreement with the client’s false ideas. The client’s behavior is likely to be reinforced if the nurse takes steps to agree with the false ideas the client holds.

Question 5.    
A client reports having thoughts of being followed by foreign agents who are after his secret papers. Which response by the nurse is most appro¬priate when responding to the client’s disturbed thought process?
(a) “I don’t see any foreign agents.”
(b) “I think these thoughts are frightening to you.”
(c) “I don’t know what you mean.”
(d) “I would like you to come to group with me right now.”
Answer:
(b) “I think these thoughts are frightening to you.”

Explanation:
The client’s disturbed thought process likely reflects this client’s paranoid delusions. The nurse should acknowledge that the thoughts are frightening the client. Telling the client the nurse does not see any foreign agents is an appropriate nursing response if the client is having disturbed visual sensory perception and is having visual hallucinations.

Telling the client the nurse does not understand what the client means is an appropriate response if the client has impaired verbal communication. Suggesting that a client participate in group activities would be appropriate if the client had a nursing diagnosis of social isolation and was staying in his room.

Question 6.    
The police bring a client to the emergency department after she threatens to kill her ex-husband. The client states emphatically, “The police should bring him in, not me. He is paranoid about my dating and has been stalking me for weeks. He is probably off his medicines. His case manager and the police will not do anything.” In what order should the following nursing actions be done from first to last? All options must be used.
(a) Ask about the marital problems leading to the divorce.
(b) Assess the client’s risk for harm to self and others.
(c) Obtain the name of her ex-husband’s case manager.
(d) Interview the client about her current needs and situation.
Answer:
(b) Assess the client’s risk for harm to self and others.
(d) Interview the client about her current needs and situation.
(c) Obtain the name of her ex-husband’s case manager.
(a) Ask about the marital problems leading to the divorce.

Explanation:
(b), (d), (c), (a) The nurse should first assess the client’s risk for harm, especially because the client could direct her anger toward her ex-husband or the nurse. Then it is important to know more about her current situation and her immediate needs. Obtaining information from the ex-husband’s case manager might help clarify the risk of harm to the client. Problems leading to the divorce are less important than the situation following the divorce.

Question 7.    
A client who has been stabilized on medications for several months is at the clinic for a medication check. During a conversation with the nurse, the client suddenly jumps up, begins pacing, and wrings her hands. In what order should the nurse do the following interventions from first to last? All options must be used.
(a) Walk with the client to help decrease her anxiety.
(b) Discuss productive ways to solve her problems causing anxiety.
(c) Share observations about her anxiety-related behaviors.
(d) Ask the client about the sources of her anxiety.
Answer:
(a) Walk with the client to help decrease her anxiety.
(c) Share observations about her anxiety-related behaviors.
(d) Ask the client about the sources of her anxiety.
(b) Discuss productive ways to solve her problems causing anxiety.

Explanation:
(a), (c), (d), (b) The nurse should first walk with the client to reduce her anxiety because the client must be at a mild level of anxiety before learning can occur. Sharing observations with the client conveys a sense of caring. Later, the nurse can help the client connect the anxiety-related behaviors to her feelings of anxiety. Once the client can identify the source of her anxiety, she can talk about solutions.

Question 8.    
A client on haloperidol has stiff muscles, restlessness, and internal jumpiness. The client has all of the following medications prescribed as needed. Which one would be most appropriate for the nurse to administer to decrease the client’s symptoms?
(a) lorazepam
(b) benztropine
(c) trazodone
(d) olanzapine
Answer:
(b) benztropine

Explanation:
The reported symptoms are signs of extra- pyramidal side effects. The medication of choice is benztropine, an antiparkinson medicine. Lorazepam is an antianxiety agent. Trazodone is an antidepressant used to enhance sleep. Olanzapine is an antipsychotic medication that could aggravate the extrapyramidal side effects.

Question 9.    
The parents of a 20-year-old female client diagnosed with paranoid schizophrenia admitted 4 days ago are attending a family psychoeducation group in the hospital. Which statement by the mother indicates that she understands her daughter’s illness and management?
(a) “I know that I’ll have to do everything for my daughter when she comes home.”
(b) “Tasks as simple as getting out of bed and showering in the morning may be difficult for her.”
(c) “I know that visits from her friends at home should be discouraged for a while.”
(d) “She won’t experience a relapse as long as she takes her prescribed medication.”
Answer:
(b) “Tasks as simple as getting out of bed and showering in the morning may be difficult for her.”

Explanation:
Clients with paranoid schizophrenia experience alterations in thought resulting in introspection, confusion, and distraction from external reality. Simple tasks that require concentration and effort, including activities involving self-care, may be difficult for the client, especially during the acute phase of the illness. However, the mother should not need to do everything for her daughter. 

Rather, the mother should encourage the daughter to do things for herself with guidance. Visits from friends should be discussed with the client, and the client should be encouraged to visit with friends to minimize the risk of social isolation. Although relapse typically occurs with medication noncompliance, vulnerability to stress, a low threshold for stress, the number of stresses, and the client’s lack of adaptive coping behaviors contribute to relapse.

Question 10.    
During a home visit for a client diagnosed with paranoid schizophrenia discharged 1 week ago, the client’s mother tearfully states, “I can hardly sleep because I’m so worried about my daughter. I’m afraid to leave her alone in the house. What if something should happen while I am gone?” Which caregiver problem would be the most inclusive one for the nurse to incorporate into the client’s plan of care?
(a) caregiver role strain
(b) anxiety
(c) fear
(d) disturbed sleep pattern
Answer:
(a) caregiver role strain

Explanation:
The nurse recognizes the mother’s feelings of being overwhelmed with the issues concerning the management of her daughter at home as caregiver role strain. Anxiety, fear, and sleep disturbances all contribute to caregiver role strain. The nurse should help the mother elicit the support of other family members or friends, continue with psychoeducation, and help the family connect with a support group.

Question 11.
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?
(a) thought content
(b) quality of speech
(c) insight
(d) judgment
Answer:
(a) thought content

Explanation:
The client is voicing paranoid delusions of being followed and monitored. Presence of delusions is described in the area of thought content in the mental status examination. The speech section would typically include documentation of disturbances in speech or pressured speech. In the insight section, the nurse would document information reflecting a lack of insight for example, statements such as "I don’t have a problem.” In the judgment section, the nurse would document information reflecting a lack of judgment for example, poor choices such as buying a gun for self-protection.

Question 12.
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 isn’t he eating? He’s still talking about his food being poisoned.” Which appraisal by the nurse is most accurate?
(a) The wife’s inquiry is reasonable.
(b) Education about her husband’s medications is needed.
(c) Her expectations of her husband are realistic.
(d) An increase in the client’s medication is indicated.
Answer:
(b) Education about her husband’s medications is needed.

Explanation:
For the client with paranoid schizophrenia, 2 days on medication is too short a time for improvement to be seen. Therefore, the nurse evaluates the client’s wife as needing education or knowledge about paranoid schizophrenia, the course of the illness, and medications. Expecting an absence of delusions by the end of the client’s 2nd day of hospitalization is unrealistic. 

Rather, the nurse would reasonably expect delusions to decrease, disappearing by 5 to 9 days of hospitalization. The wife’s inquiry is not reasonable because not enough time has elapsed to evaluate the effectiveness of treatment. An increase in the client’s medication would be unreasonable because not enough time has elapsed to evaluate the effectiveness of the medication. Generally, a time frame of 5 to 7 days is needed before the effectiveness of medications can be determined.

Question 13.
A client states that she hears God’s voice telling her that she has sinned and needs to punish herself. Which response by the nurse is most important?
(a) “How do you think you’ll be punished?”
(b) “Do you think you need to punish yourself now?”
(c) “What exactly do you think you’ve done to be punished?”
(d) “Let’s talk about your strengths.”
Answer:
(b) “Do you think you need to punish yourself now?”

Explanation:
The client is at risk for harming herself because of the command auditory hallucinations. It is most important for the staff to know if she currently thinks she needs to punish herself. Then  it is important to know how she thinks she might punish herself. Knowing what she thinks she has done is relevant for changing her negative thinking. Focusing on her strengths would help improve her self-esteem.

Question 14.
When developing the plan of care for a client who is staying in his room because he perceives that staff want to harm him, which outcome of care plan¬ning is most realistic?
(a) Within 2 days, the client will complete activities of daily living.
(b) Within 3 days, the client will participate in recreation with other clients.
(c) Within 4 days, the client will demonstrate an absence of verbal aggression.
(d) Within 5 days, the client will seek out staff to talk about feelings.
Answer:
(d) Within 5 days, the client will seek out staff to talk about feelings.

Explanation:
The client is exhibiting suspiciousness of and a lack of trust in the staff, not aggression. Seeking out staff indicates the development of trust and decreased suspiciousness. Although completing activities of daily living and participating in recreation with other clients are important, the major problem presented is related to the client’s isolation and perception of being harmed not, for example, showering, hygiene, or other clients.

Question 15.
A client diagnosed with paranoid schizophrenia is still withdrawn, unkempt, and unmotivated to get out of bed. An unlicensed assistive personnel (UAP) asks the nurse why the client is behaving this way after being on fluphenazine 10 mg for 7 days. What should the nurse tell the UAP?
(a) “Fluphenazine is most effective with the positive symptoms of schizophrenia.”
(b) “The client will be less withdrawn and unmotivated when the fluphenazine takes effect.”
(c) “The client’s fluphenazine dose probably needs to be increased again.”
(d) “Lack of motivation is a common side effect of fluphenazine.”
Answer:
(a) “Fluphenazine is most effective with the positive symptoms of schizophrenia.”

Explanation:
Fluphenazine is most effective with the positive symptoms of schizophrenia. The client’s symptoms reflect the negative symptoms. Fluphenazine generally is effective in 3 to 7 days for the positive symptoms. An increased dose or longer time on fluphenazine will not help the negative symptoms of being withdrawn and unmotivated.

Question 16.
A pregnant client in her third trimester is started on chlorpromazine 25 mg 4 times daily. Which instructions are most important for the nurse to include in the client’s teaching plan?
(a) “Don’t drive because there is a possibility of seizures occurring.”
(b) “Avoid going out in the sun without a sunscreen with a sun protection factor of at least 30.”
(c) “Stop the medication immediately if constipation occurs.”
(d) “Tell your health care provider (HCP) if you experience an increase in blood pressure.”
Answer:
(b) “Avoid going out in the sun without a sunscreen with a sun protection factor of at least 30.”

Explanation:
Chlorpromazine is a low-potency antipsychotic that is likely to cause sun-sensitive skin. Therefore, the client needs instructions about using sunscreen with a sun protection factor of 30 or higher. Typically, chlorpromazine is not associated with an increased risk of seizures. Although constipation is a common adverse effect of this drug, it can be managed with diet, fluids, and exercise. 

The drug does not need to be discontinued. Chlorpromazine is associated with postural hypotension, not hypertension. Additionally, if postural hypotension occurs, safety measures, such as chang¬ing positions slowly and dangling the feet before arising, not stopping the drug, are instituted.

Question 17.
A client reports that men in blue clothes keep looking in her window and talking about her. Which response by the nurse is most appropriate?
(a) “Those men are groundskeepers. They are talking about their work, not you.”
(b) “Don’t take things so personally. Not everyone who is talking is talking about you.”
(c) “Let’s not pay attention to the men. Let’s play cards instead.”
(d) “I’ll close the drapes so you can’t see the men.”
Answer:
(a) “Those men are groundskeepers. They are talking about their work, not you.”

Explanation:
The nurse needs to present the reality of the situation. By explaining that the men are groundskeepers and probably talking about work, the nurse is reinforcing reality to counter the client’s illusion (misinterpretation of reality). Additionally, this response voices doubt in the client’s paranoid interpretation. Telling the client not to take things personally is flippant and judgmental. Telling the client to not pay attention to the men fails to address the client’s misinterpretations and misperceptions. Closing the drapes so that the client does not see the men ignores the client’s misperceptions and misinterpretation.

Question 18.
When preparing the teaching plan for a client who is to start clozapine, which information is crucial to include?
(a) description of akathisia and drug-induced parkinsonism
(b) measures to relieve episodes of diarrhea
(c) the importance of reporting insomnia
(d) an emphasis on the need for weekly blood tests
Answer:
(d) an emphasis on the need for weekly blood tests

Explanation:
Clozapine is associated with agranulocytosis. Therefore, the nurse must instruct the client about the need for weekly blood tests to monitor for this adverse effect. Akathisia and drug-induced parkinsonism are associated with high-potency antipsychotics. These effects are not common with this atypical antipsychotic agent. Constipation and sedation may occur with this drug.

Question 19.
A client is sitting in the corner of the day- room cocking his head to one side as if he hears something, but no one is nearby. The nurse suspects he is having auditory hallucinations. Which question should the nurse ask first?
(a) “Are you seeing someone other than me?”
(b) “What are you hearing right now?”
(c) "What is going on with you right now?”
(d) "Do you want to go to the recreation room?”
Answer:
(b) “What are you hearing right now?”

Explanation:
Before intervening with the client experiencing hallucinations, the nurse must validate what the client is experiencing. Asking the client what he hears right now accomplishes this. Asking about seeing someone near the client would be appropriate to validate visual hallucinations. Asking the client about what is going on may be helpful. However, the question is too general to validate that the client is experiencing auditory hallucinations. Asking the client if he wants to go to the recreation room might be appropriate after the nurse has validated what the client is experiencing.

Question 20. 
A client who is newly diagnosed with paranoid schizophrenia tells the nurse, “The aliens are telling me that I am defective and need to be eliminated.” Which response by the nurse is most appropriate initially?
(a) “I know those voices are real to you, but I don’t hear them.”
(b) “You’re having hallucinations as a result of your illness.”
(c) “I want you to agree to tell staff when you hear these voices.”
(d) “Your medications will help control these voices you are hearing.”
Answer:
(c) “I want you to agree to tell staff when you hear these voices.”

Explanation:
The client may act on command hallucinations and harm himself or others. Therefore, the staff needs to know when the client is hearing such commands, to ensure safety first. Telling the client that the voices are real but that the nurse does not hear them would be an appropriate response later in the client’s hospitalization when the client’s safety is no longer an issue because antipsychotics are beginning to take effect. 

Telling the client that the hallucinations are part of the illness or that medications will help control the voices would be appropriate once the client has developed some insight into the symptoms of the illness.

Question 21.
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?
(a) alcohol intoxication
(b) ineffectiveness of risperidone
(c) alcohol withdrawal
(d) interaction of alcohol and risperidone
Answer:
(a) alcohol intoxication

Explanation:
Tactile hallucinations are more common in alcohol withdrawal than in schizophrenia. Therefore, the nurse should explain that these hallucinations are the result of withdrawal from alcohol. Because the client stopped drinking 4 days ago, the client is not intoxicated. Risperidone has little effect on symptoms of alcohol withdrawal. It is prescribed for symptoms of schizophrenia. Alcohol and ris-peridone have an additive effect, not one of causing hallucinations. 

Question 22. 
A client with a long history of paranoid schizophrenia is readmitted voluntarily after missing his last two injections of haloperidol. He reports, “I’m not sleeping much, and my friend says I smell from not showering. God is telling me to protect myself from others. My parents are sick and tired of me and my illness. They wish I were dead.” Which admission notes by the nurse contains assumptions and potentially false accusations? Select all that apply.
(a) Client has been noncompliant with his medications, causing decreased sleep and activities of daily living, increased auditory hallucinations, and paranoid delusions about his parents harming him.
(b) Client has missed two injections of haloperidol and was admitted voluntarily. He reports he has decreased sleep and showering and that he hears God’s voice telling him to protect himself from others. He stated, “My parents are sick and tired of me and my illness. They wish I were dead.”
(c) Client has missed two doses of haloperidol. He is not sleeping and showering. Has a strained relationship with his parents and delusions that they want him dead. Voluntary admission to restart haloperidol.
(d) Client admitted for noncompliance with haloperidol injections, sleep disturbance, poor hygiene, auditory hallucinations, and suspiciousness of his parents. Needs to be monitored for suicidal and homicidal ideation.
(e) Client admitted because of hallucinations and delusions. His parents may be abusing him. He states he has not taken his medications for 2 days.
Answer:
(a) Client has been noncompliant with his medications, causing decreased sleep and activities of daily living, increased auditory hallucinations, and paranoid delusions about his parents harming him.
(d) Client admitted for noncompliance with haloperidol injections, sleep disturbance, poor hygiene, auditory hallucinations, and suspiciousness of his parents. Needs to be monitored for suicidal and homicidal ideation.
(e) Client admitted because of hallucinations and delusions. His parents may be abusing him. He states he has not taken his medications for 2 days.

Explanation:
(a), (d), (e) Documentation provided in option 2 is the most factual and without conclusions or assumptions. Stating that the client was noncompliant with medications is not the only cause of decreased sleep and activities of daily living or increased delusions and hallucinations. Also, the client did not say that his parents wanted to harm him directly. 

Stating that the client’s relationship with his parents is strained is an assumption, even if he did indeed state that they wanted him dead. The client does not state a wish to be dead or harm others, although further assessment would be necessary. Documenting that his parents may be abusing him makes an assumption, although the nurse should further assess for this possibility.

Question 23. 
A newly admitted client diagnosed with paranoid schizophrenia is pacing rapidly and wringing his hands. He states that another client is out to get him. Then he says, “Protect me, select me, reject me.” What should the nurse do next?
(a) Administer his oral PRN lorazepam and haloperidol.
(b) Place the client in temporary seclusion.
(c) Call the health care provider (HCP) for a prescription for restraints.
(d) Ask the other clients to leave the immediate area.
Answer:
(a) Administer his oral PRN lorazepam and haloperidol.

Explanation:
The client’s anxiety as reflected in rapid pacing and clang associations is rising as a result of his paranoid delusions. Administering the loraz- epam and haloperidol will help the anxiety and delusions. The client is not threatening others at this point, so seclusion, restraints, and asking clients to leave the area are not necessary.

Question 24.
A new nurse is leading a family education group for those who have relatives with paranoid schizophrenia. Which statement by the new nurse indicates the need for further teaching about symptom management?
(a) “When the clients get overwhelmed, it’s best if they spend some time in their room.”
(b) “The more we push the clients to spend time with friends, the more their voices decrease.”
(c) “Until we get the clients up and going, they seem to have no motivation to do anything.”
(d) “We still have to remind the clients that we do not hear the voices they do.”
Answer:
(b) “The more we push the clients to spend time with friends, the more their voices decrease.”

Explanation:
Pushing a suspicious client into social situations is likely to increase anxiety, which increases, not decreases, the hallucinations. The statement about spending some time alone if the client is overwhelmed indicates awareness and understanding of how to intervene when the client is exposed to stress. The statement about lack of motivation indicates awareness and understanding of avolition. The statement about reminding the client that the family does not hear the voices indicates awareness and understanding of the client’s hallucinations.

Question 25. 
A client is being successfully treated with clozapine. Which statement by the client reflects a need for further teaching about managing the drug’s adverse effects?
(a) “If I eat too many fruits, I’ll get constipated.”
(b) “I need to take the medicine with food to avoid nausea.”
(c) “I have to get up slowly so I don’t get dizzy.”
(d) “Sometimes I have to push myself because I’m sleepy.”
Answer:
(a) “If I eat too many fruits, I’ll get constipated.”

Explanation:
Clozapine is the one atypical antipsychotic associated with severe anticholinergic adverse effects such as constipation. Consuming fruits would not be the cause of the client’s constipation. The client should take clozapine with food to avoid nausea. Getting up slowly indicates that the client understands that postural hypotension may occur with clozapine. The statement about sleepiness indicates that the client understands that sedation may occur with this drug.

Question 26. 
Which statement indicates increased insight by the client about her newly diagnosed paranoid schizophrenia being stabilized on medications?
(a) “Now that the voices are gone, I can decrease my medicines.”
(b) “I’d feel better if I knew there wasn’t poison in my food.”
(c) “Since I feel better, I know I can restart school next week.”
(d) “The voices go away when I tell them to, except if I'm really nervous.”
Answer:
(d) “The voices go away when I tell them to, except if I'm really nervous.”

Explanation:
The statement about the voices occurring if the client is nervous reflects awareness that stress and anxiety can increase the positive symptoms of schizophrenia. Decreasing the medications because the voices are gone reveals a lack of awareness about the need for the medications to control the client’s symptoms. Stating that there is still poison in her food demonstrates a lack of insight into the client’s delusions. Restarting school in a week reflects an unrealistic expectation for a client who is newly diagnosed and being stabilized on medications.

Question 27. 
A client who is suspicious of others, including the staff, is brought to the hospital wearing a wrinkled dress with stains on the front. Assessment also reveals a flat affect, confusion, and slow movements. Which goal should the nurse identify as the initial priority when planning this client’s care?
(a) helping the client feel safe and accepted
(b) introducing the client to other clients
(c) giving the client information about the program
(d) providing the client with clean, comfortable clothes
Answer:
(a) helping the client feel safe and accepted

Explanation:
The initial priority for this client is to help her overcome suspiciousness of others, including staff, and thereby feel safe and accepted. Introducing the client to others, giving the client information about the program, and providing clean clothes are important, but these are of lower priority than helping the client feel safe and accepted.

Question 28.    
The parent of a young adult client diagnosed with paranoid schizophrenia is asking questions about his son’s antipsychotic medication, ziprasi-done. Which statement by the parent reflects a need for further teaching?
(a) “If he experiences restlessness or muscle stiffness, he should tell his health care provider (HCP).”
(b) “I should give him benztropine to help prevent constipation from the ziprasidone.”
(c) “If he becomes dizzy, I’ll make sure he doesn’t drive.”
(d) “The ziprasidone should help him be more motivated and less withdrawn.”
Answer:
(b) “I should give him benztropine to help prevent constipation from the ziprasidone.”

Explanation:
Constipation caused by medication is best managed by diet, fluids, and exercise. Benztropine can increase constipation. However, it may be prescribed for restlessness and stiffness. Restlessness and stiffness should be reported to the HCP TO. Drowsiness and dizziness are adverse effects of ziprasidone. Clients should not drive if they are experiencing dizziness. Ziprasidone does help improve the negative symptoms of schizophrenia such as avolition.

Question 29.    
While the nurse is performing an admission assessment, the client stops talking in the middle of a sentence, tips his head to the side, and listens carefully. The nurse recognizes that the client is most likely experiencing which problem?
(a) somatic delusions
(b) pseudoparkinsonism
(c) delusions of reference
(d) auditory hallucinations
Answer:
(d) auditory hallucinations

Explanation:
When the client is listening to the voices, it is most likely an auditory hallucination. Somatic delusions are false beliefs about the functioning of the client’s own body. Pseudoparkinsonism is another name for the extrapyramidal symptoms of the medications. Delusions of reference involve events within the environment.

Question 30.    
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 don’t want to take this ziprasidone either. I can’t gain any more weight.” Which response by the nurse is most appropriate for this client?
(a) “Ziprasidone causes less weight gain than do the other atypical antipsychotics.”
(b) “We can give it to you as an injection rather than in capsule form.”
(c) “Abnormal movements are not as common with ziprasidone.”
(d) “You can take it just before bedtime, so you won’t need a snack.”
Answer:
(a) “Ziprasidone causes less weight gain than do the other atypical antipsychotics.”

Explanation:
Most clients experience less weight gain when taking ziprasidone. Although ziprasidone can be administered intramuscularly, it can be used only on an as-needed basis by this route. Ziprasidone has fewer extrapyramidal side effects, but that is not this client’s major concern. Ziprasidone is better absorbed when taken with food, so a bedtime snack is needed.

Question 31. 
As hospital-based care has become more oriented to crisis intervention, criteria for admission to the hospital have also changed. Which clients have priority for admission to an acute care facility? Select all that apply.
(a) clients who live alone
(b) clients who are acutely psychotic
(c) clients who are acutely depressed
(d) clients who are dangerous to self or others
(e) clients who are not sleeping and have a lack of appetite
(f) clients who are not complying with medication regimens
Answer:
(b) clients who are acutely psychotic
(d) clients who are dangerous to self or others

Explanation:
(b), (d) Safety issues, including protection of the client and others, are the priorities for admission. Acute psychosis commonly involves issues of safety. Living alone is not a sufficient reason to be  admitted to a health care facility. Depression, insomnia, lack of appetite, and noncompliance are important issues but not sufficient for admission unless combined 

Question 32. 
An older adult client is brought to the outpatient clinic by her daughter for a routine medication evaluation. The daughter reports that her mother is quite stable and has no adverse effects from the risperidone she is taking. Then, the daughter says, “I just think my mother could be even better if she was on a larger dosage. My son takes 1 mg of risperidone every day and my mother is only on 0.5 mg.” What is the most helpful response by the nurse?
(a) “Maybe your son is sicker than your mother is.”
(b) “We could increase your mother’s dosage if you want.”
(c) “Older clients generally need lesser doses than do younger people.”
(d) “I am not seeing any symptoms of illness in your mother. Let us wait until the next visit.”
Answer:
(c) “Older clients generally need lesser doses than do younger people.”

Explanation:
Older adult clients are typically on lower dosages of antipsychotic medications because of the metabolic changes of aging. Comparing dosages is not relevant. Each client is unique in metabolizing medications. Changing medication dosages is based on an assessment of illness symptoms and the adverse effect profile, not on family preferences. Urging the daughter to wait discounts her concerns and gives no rationale for waiting.

Question 33.    
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’ve gained 20 lb (9.1 kg) already. I can’t stand it anymore.” Which response by the nurse is most appropriate?
(a) “I don’t think you look fat; why do you think so?”
(b) “I can help you with a diet and exercise plan to keep your weight down.”
(c) “You can be switched to another medicine.”
(d) “Your weight gain will level off if you stay on the medication 3 more months.”
Answer:
(b) “I can help you with a diet and exercise plan to keep your weight down.”

Explanation:
Helping the client control his weight is the most appropriate approach. The nurse’s contradiction of the client’s statement is inappropriate. Most atypical antipsychotics cause weight gain and are not a solution to the weight gain. There is little evidence that weight gain from taking olanzapine decreases with time.

Question 34.    
A client diagnosed with schizophrenia is being switched to risperidone long-acting injection. The client is told that he will remain on his oral dose of risperidone daily for approximately 1 month. The client says, “I didn’t have to take pills when I was on fluphenazine shots in the past.” What should the nurse tell the client?
(a) “Taking fluphenazine orally and by injection would not be as effective as the injection alone.”
(b) “Risperidone is less potent than fluphenazine.”
(c) “Your health care provider did not believe you would take both the pills and fluphenazine injections.”
(d) “Risperidone initially takes a little longer to reach the ideal blood level.”
Answer:
(d) “Risperidone initially takes a little longer to reach the ideal blood level.”

Explanation:
Achieving a therapeutic blood level is a slower process with risperidone long-acting injection. Oral fluphenazine does not decrease the effectiveness of the intramuscular version and might increase the incidence of adverse effects. There is no evidence that the potency of the two medications is significantly different. Blaming the client for noncompliance with these two medications is inappropriate.

Question 35.    
The nurse is instructing the client who has a prescription for lurasidone HCL for schizoaffective disorder. Which nursing instruction is the most appropriate?
(a) “Take the dose in the morning with a full breakfast of eggs, toast, juice, and coffee.”
(b) “Take the dose in the evening with a sandwich and a glass of milk.”
(c) “Take the dose at noon with an apple and celery.”
(d) “Take the dose in the midafternoon with water.” 
Answer:
(b) “Take the dose in the evening with a sandwich and a glass of milk.”

Explanation:
Lurasidone HCL should be taken in the later hours of a day with a total of 350 calories. A sandwich and a glass of milk will provide this number of calories. Another effect of lurasidone is drowsiness after administration, so taking it in the evening is preferred by many clients. Taking the medication in the morning with the large breakfast provides too many calories and allows the drowsiness to manifest. Taking with an apple and celery or just water also is not enough calories. Clients report abdominal discomfort.

Question 36.    
A client perceives that her roommate’s stuffed animal is her own dog at home. The nurse determines that this misperception of reality (illusion) is improving when the client makes which statement?
(a) “Jan’s stuffed dog looks somewhat like my dog.”
(b) “Jan’s dog and my dog could be twins.”
(c) “I wish Jan had not had my dog stuffed.”
(d) “I guess Jan needs a dog as much as I do.”
Answer:
(a) “Jan’s stuffed dog looks somewhat like my dog.”

Explanation:
Recognition by the client that there is a difference between the stuffed animal and her live dog indicates that the client perceives the reality of the situation. Stating that the stuffed animal and  the client’s dog could be twins reflects the client’s continued misperception of reality, thinking that the stuffed animal and her dog are one and the same. Stating that she wishes her dog had not been stuffed reflects her continued misperception of reality. Stating that the roommate needs a dog as much as she does is unrelated to the client’s perception or misperception of reality.

Question 37 . 
When asked about her stresses before admission, an anxious client stares blankly at the nurse and mutters unintelligibly. Which description of the client’s behaviors should the nurse document in the client’s medical record?
(a) “Client cannot answer any questions asked at this time.”
(b) “Client is uncooperative during the admission procedure, refusing to answer any questions.”
(c) “Client responded to questions with a blank look and incomprehensible mumble.”
(d) “Client stared at the wall when asked questions and was disoriented and incoherent.”
Answer:
(c) “Client responded to questions with a blank look and incomprehensible mumble.”

Explanation:
The nurse must be objective in documenting the client’s behavior, recording exactly what the client did or did not say or do in a particular situation. Recording that the client could not answer any questions, was uncooperative and refused to answer questions, or was disoriented and incoherent is not described and is a subjective interpretation on the nurse’s part.

Question 38.    
When planning care for a client with schizophrenia who lacks motivation to shower and dress, which outcome should the nurse expect the client to achieve by the end of 4 days?
(a) Verbalize the need to shower and dress herself.
(b) Recognize the need to shower and dress herself.
(c) Explain reasons for showering and dressing herself.
(d) Perform showering and dressing for herself.
Answer:
(d) Perform showering and dressing for herself.

Explanation:
By the end of 4 days, the client should be able to perform showering and dressing for herself. The client with schizophrenia commonly appears to be apathetic and lack initiative. Therefore, demonstrating the ability to complete the tasks indicates improvement. Although the client may be able to recognize, verbalize, or explain the need to shower and dress herself, she may be unable to do so because of the ambivalence associated with schizophrenia that impedes the client’s ability to initiate and complete self-care. Therefore, evidence of improvement would be lacking.

Question 39.    
A client diagnosed with schizophrenia is brought to the hospital from a group home where he became agitated, threw a chair at another client, and has been refusing medication for 8 weeks. The client exhibits a flat affect, is not caring for his hygiene, and has become increasingly withdrawn and asocial. The health care provider prescribes treatment with risperidone to improve the client’s negative and positive symptoms of schizophrenia. When evaluating the drug’s effectiveness on the client’s negative symptoms, the nurse should expect improvement in which symptom?
(a) apathy, affect, social isolation
(b) agitation, delusions, hallucinations
(c) hostility, ideas of reference, tangential speech
(d) aggression, bizarre behavior, illusions
Answer:
(a) apathy, affect, social isolation

Explanation:
When determining the effectiveness of risperidone, the nurse would expect improvement in the client’s negative symptoms of apathy, flat affect, and social withdrawal. Delusions, hallucinations, illusions, and ideas of reference are positive symptoms of schizophrenia. Agitation, hostility, and aggression are also the result of the positive symptoms.

Question 40. 
A 77-year-old client is brought to the emergency department by her son. The client has a severe headache and lack of sleep because “I am so worried about everything.” Her son says that she has heart failure and chronic schizophrenia. “In addition to all of her heart medicines, she’s on aripiprazole, which was increased to 30 mg by her health care provider (HCP) 3 days ago.” In addition to documenting all of the client’s medications and exact dosages, the nurse should particularly investigate which factors? Select all that apply.
(a) the qualifications of the client’s HCP
(b) the client’s symptoms of schizophrenia
(c) the dose of aripiprazole
(d) the client’s symptoms of heart failure
(e) the client’s relationship with her son
Answer:
(b) the client’s symptoms of schizophrenia
(c) the dose of aripiprazole
(d) the client’s symptoms of heart failure

Explanation:
(b), (c), (d) The client’s symptoms are likely to be adverse effects of aripiprazole, especially at the reported dose. The normal adult dose is 5 to 10 mg. The older adult client commonly needs a lower dose compared with other adults. The anxiety and sleep disturbance could be symptoms of schizophrenia or medication adverse effects. A holistic approach would include assessing the client’s heart failure. Questioning the qualifications of the family HCP is unproductive. There are no indications of problems in the client’s relationship with her son. 

Question 41. 
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?
(a) delusion, requiring further assessment
(b) unusual reaction to clozapine
(c) expected adverse effect of clozapine
(d) unresolved symptom of schizophrenia
Answer:
(c) expected adverse effect of clozapine

Explanation:
Excessive salivation, or sialorrhea, is commonly associated with clozapine therapy. The client can use a washcloth to wipe the saliva instead of spitting. It is an expected adverse effect of the drug, not a delusion, an unusual reaction, or an unresolved symptom of schizophrenia.

Question 42. 
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?
(a) performing rituals, avoiding open places
(b) elevated mood, hyperactivity, distractibility
(c) poor eye contact, tilted head, mumbling to self
(d) distrust, fear, suspicion
Answer:
(c) poor eye contact, tilted head, mumbling to self

Explanation:
Cues that the client is experiencing auditory hallucinations include eyes looking around the room as though looking for a speaker, tilting the head to one side as though listening, and mumbling or talking aloud as though responding to someone. Performing rituals and avoiding open places is associated with anxiety and compulsive behaviors. Elevated mood and hyperactivity are features of a manic episode. Distrust and suspicion are prevalent in paranoia.

Question 43.    
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 hand, and stares at it. What should the nurse do next?
(a) Tell the client to put the medicine in the mouth and swallow it with some water.
(b) Instruct the client to sit in the dayroom and wait for the nurse to assist him.
(c) Ask another staff member to stay with the client until the client takes the medication.
(d) Say nothing and wait for the client to put the medication in the mouth and swallow it.
Answer:
(a) Tell the client to put the medicine in the mouth and swallow it with some water.

Explanation:
The nurse instructs the client clearly and directly to put the medication in the mouth and then to swallow it with some water. Clear, step-by-step directions assist the client to process what the nurse is saying. Telling the client to sit in the dayroom and wait, asking another staff member to stay with the client, or saying nothing is not helpful.

Question 44.    
Which action by the nurse is most likely to increase the anxiety and suspiciousness of a client who is delusional?
(a) informing the client of schedule changes
(b) whispering with others where the client can observe
(c) telling the client gently that the nurse does not share the client’s view
(d) inviting the client to join in leisure activities
Answer:
(b) whispering with others where the client can observe

Explanation:
Whispering and laughing with another person where the client can see or observe the nurse but not hear the conversation increases the client’s anxiety and suspiciousness. Therefore, this action should be avoided. Informing the client of schedule changes, telling the client gently that the nurse does not share the client’s interpretation of an event, and inviting the client to participate in leisure activities help the client to decrease anxiety and suspiciousness and to focus on actual or realistic events.

Question  45.    
A client with schizophrenia tells the nurse that he does not go out much because he does not have anywhere to go, and he does not know anyone in the apartment where he is staying. Which action is most beneficial for the client at this time?
(a) encouraging him to call his family to visit more often
(b) making an appointment for the client to see the nurse daily for 2 weeks
(c) thinking about the need for rehospitalization for the client
(d) arranging for the client to attend day treatment at the clinic
Answer:
(d) arranging for the client to attend day treatment at the clinic

Explanation:
Because the client can live in an apartment setting, further development of independent functioning and the skills to gain as much independence as he is capable of need to be fostered, including getting out and developing new friendships. Arranging for participation in day treatment is most beneficial at this time. Family visits and daily nursing visits do not encourage the client to do this. Making an appointment for 2 weeks later puts the client’s needs off. Lack of social relationships is not a sufficient reason for rehospitalization.

Question 46.    
The plan of care for an outpatient client with schizophrenia includes risperidone therapy. The nurse prepares to administer this drug based on the understanding of which factor?
(a) The positive symptoms of schizophrenia are usually more prominent than the negative symptoms.
(b) Agranulocytosis is less of a risk with risperidone therapy than with clozapine.
(c) Typical antipsychotics help with negative symptoms, but not as well as risperidone does.
(d) Risperidone is less expensive than traditional antipsychotics.
Answer:
(b) Agranulocytosis is less of a risk with risperidone therapy than with clozapine.

Explanation:
One advantage of using risperidone is that it is not associated with agranulocytosis like clozapine and does not require the same lab monitoring. In schizophrenia, negative symptoms are more prominent than positive. Negative symptoms do not respond to typical antipsychotics such as haloperidol. Agranulocytosis is commonly associated with clozapine. Because it is a newer drug, risperidone usually is more expensive than typical antipsychotics.

Question 47.    
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.
(a) headaches
(b) transient mild anxiety
(c) insomnia
(d) torticollis
(e) pill rolling movements
Answer:
(a) headaches
(b) transient mild anxiety
(c) insomnia

Explanation:
(a), (b), (c) Headaches, transient anxiety, and insomnia are the most common adverse effects of aripiprazole. Torticollis and pill rolling are more common with the older antipsychotics.

Question 48.
A newly admitted client with an acute exacerbation of psychotic symptoms of schizophrenia is having trouble deciding whether to live in a group home or a supervised apartment. Based on the client’s current cognitive functioning, which activity is most appropriate for the nurse to ask the client to do initially?
(a) List the pros and cons of each housing option.
(b) Choose between apple and orange juice for breakfast.
(c) Identify why the client cannot live in an unsupervised apartment.
(d) Decide which staff member the client would like to have today.
Answer:
(b) Choose between apple and orange juice for breakfast.

Explanation:
The client is in an acute psychotic state and cannot process complex decisions or explain complex situations. Therefore, the nurse would focus on decision making involving simple choices. Listing the pros and cons of each housing option and identifying why the client cannot live in an unsupervised apartment involve complex decision making skills. Deciding which staff member to have today is a difficult and threatening decision for a client who is psychotic.

Question 49.    
An outpatient client who has been receiving haloperidol for 2 days develops muscular rigidity, altered consciousness, a temperature of 103°F (39.4°C), and trouble breathing on day 3. The nurse interprets these findings as indicating which complication?
(a) neuroleptic malignant syndrome
(b) tardive dyskinesia
(c) extrapyramidal adverse effects
(d) drug-induced parkinsonism
Answer:
(a) neuroleptic malignant syndrome

Explanation:
The client is exhibiting hallmark signs and symptoms of life-threatening neuroleptic malignant syndrome induced by the haloperidol. Tardive dyskinesia usually occurs later in treatment, typically months to years later. Extrapyramidal adverse effects (dystonia, akathisia) and drug-induced parkinsonism, although common, are not life threatening.

Question 50.    
A client with schizophrenia reports doing very little all day except sleeping and eating. Which intervention should the nurse use with this client?
(a) Schedule three meals per day to increase the amount of time the client spends out of bed.
(b) Ask a relative to call the client at least 10 times a day to decrease the sleeping.
(c) Help the client set up a daily activity schedule to include setting a wake-up alarm.
(d) Arrange for the client to move to a group home with structured activities.
Answer:
(c) Help the client set up a daily activity schedule to include setting a wake-up alarm.

Explanation:
The client with schizophrenia needs more structure every day to improve functioning. Therefore, helping the client to set up a daily activity schedule is most appropriate. However, a group home is not necessary. The client is already eating. Having meals brought in would increase the client’s dependence, not his activity level. Asking a relative to call the client 10 times per day is unrealistic given the typical daily responsibilities of a healthy relative.

Question 51.
The nurse notes that a client sitting in a chair has not gotten up in 1 hour. The client does not respond to verbal directions, and her arm has been extended over the armrest for 30 minutes.
What should the nurse do next?
(a) Assist the client out of the chair to lead her back to bed.
(b) Give PRN-prescribed doses of haloperidol and lorazepam.
(c) Ask the client to describe what she is experiencing right now.
(d) Sit quietly with the client until she begins to respond.
Answer:
(b) Give PRN-prescribed doses of haloperidol and lorazepam.

Explanation:
The client is exhibiting catatonic behavior, an acutely serious result of severe anxiety and psychosis. In this situation, the nurse needs to administer the PRN-prescribed doses of haloperidol and loraz- epam; they can be given together safely. Assisting the client out of the chair to go back to bed or sitting quietly until the client responds ignores the seriousness of the client’s condition. It is unlikely that the client can describe what is being experienced.

Question 52.
What is the most appropriate long-term goal for an outpatient client with schizophrenia who has been withdrawn from friends and family for 3 weeks?
(a) calling the client’s mother once a day
(b) attending day therapy three times a week
(c) allowing two friends to visit every day
(d) remaining out of bed for 10 hours a day
Answer:
(b) attending day therapy three times a week

Explanation:
Attending day therapy three times per week is a long-term goal that will show the most progress in overcoming withdrawal. The client’s calling his or her mother is a first step in getting out of a severe withdrawal. Allowing two friends to visit every day would be appropriate if the client is successful with calling his or her mother once a day. Insufficient information is presented in the scenario to indicate that excessive sleep is a problem.

Question 53. 
For the client with catatonic behaviors, which outcome would indicate a medication has been most effective in improving long-term behavior?
(a) The client can move all extremities occasionally.
(b) The client walks with the nurse to the client’s room.
(c) The client responds to verbal directions to eat.
(d) The client initiates simple activities without directions.
Answer:
(d) The client initiates simple activities without directions.

Explanation:
Although all the actions indicate improvement, the ability to initiate simple activities without directions indicates the most improvement in the catatonic behaviors. Moving all extremities occasionally, walking with the nurse to the client’s room, and responding to verbal directions to eat represent single steps toward the client initiating the client’s own actions.

Question 54.    
The mother of a client with schizophrenia calls the visiting nurse in the outpatient clinic to report that her daughter has not answered the phone in 10 days. “She was doing so well for months. I don’t know what’s wrong. I’m worried.” Which response by the nurse is most appropriate?
(a) “Maybe she’s just mad at you. Did you have an argument?”
(b) “She may have stopped taking her medications. I’ll check on her.”
(c) “Don’t worry about this. It happens sometimes.”
(d) “Go over to her apartment and see what’s going on.”
Answer:
(b) “She may have stopped taking her medications. I’ll check on her.”

Explanation:
Noncompliance with medications is common in the client with schizophrenia. The nurse has the responsibility to assess this situation. Asking the mother if they have argued or if the client is mad at the mother or telling the mother to go over to the apartment and see what is going on places the blame and responsibility on the mother and therefore is inappropriate. Telling the mother not to worry ignores the seriousness of the client’s symptoms.

Question 55.    
During a home visit, the nurse discovers that the client is less verbal, less active, less responsive to directions, severely anxious, and more dazed.
The nurse interprets these findings to indicate that the client needs which intervention?
(a) a sleep aid
(b) a clinic appointment
(c) an increase in medication
(d) an immediate medical evaluation
Answer:
(d) an immediate medical evaluation

Explanation:
The client is exhibiting symptoms of becoming catatonic and unable to care for himself and needs immediate evaluation and possible hospitalization. A sleep aid is not sufficient to treat this client. The client’s worsening condition dictates action without waiting for a clinic appointment. An increase in medication may be indicated, but hospitalization is required first for safety.

Question 56.    
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 prescribes a valproic acid blood level to be drawn at once. What does the nurse understand is the rationale for this prescription?
(a) All clients taking valproic acid need periodic valproic acid levels drawn.
(b) Fluoxetine can decrease the effectiveness of the valproic acid.
(c) A decrease in the level of valproic acid could explain the increase in manic symptoms.
(d) The valproic acid level is needed before a short course of lorazepam for agitation can be prescribed.
Answer:
(c) A decrease in the level of valproic acid could explain the increase in manic symptoms.

Explanation:
Valproic acid is commonly used to treat manic symptoms. Therefore, a decrease in the valproic acid level could explain the increase in manic symptoms. Periodic determinations of the valproic acid level are necessary to determine the effectiveness of the drug. However, the stat nature of the specimen to be drawn indicates an immediate problem. Fluoxetine is not known to decrease the effectiveness of valproic acid. The valproic acid level is not needed before beginning a short course of therapy with lorazepam.

Question 57.    
A 22-year-old client is being admitted with a diagnosis of brief psychotic disorder. Which finding would the nurse expect to find during the admis¬sion interview that is consistent with the client’s diagnosis?
(a) current treatment for pneumonia
(b) regular use of alcohol or marijuana
(c) evidence of delusions or hallucinations
(d) a history of chronic depression
Answer:
(c) evidence of delusions or hallucinations

Explanation:
A diagnosis of brief psychotic disorder is made when the client exhibits delusions, hallucinations, and disorganized speech or behaviors in the absence of a mood disorder, substance-induced disorder, or general medical condition.

Question 58.
A client brought to the clinic after being arrested for harassing and stalking his ex-wife denies any other symptoms or problems except anger about being arrested. The ex-wife reports to the police, “He’s fine except for this irrational belief that we’ll remarry.” When collaborating with the health care provider about a plan of care, which intervention would be most effective for the client at this time?
(a) a prescription for olanzapine 10 mg daily
(b) a joint session with the client and his ex-wife
(c) a prescription for fluoxetine 20 mg every morning
(d) referral to an outpatient counselor Clients and Families Affected by Chronic Mental Illnesses
Answer:
(d) referral to an outpatient counselor Clients and Families Affected by Chronic Mental Illnesses

Explanation:
Follow-up counseling is appropriate because of the client’s anger and inappropriate behaviors. The goal is to help the client deal with the end of his marriage. A joint session might have been useful before the divorce and arrest, but not after. The client is exhibiting no signs or symptoms of schizophrenia or psychosis, so olanzapine is not indicated. The client is not exhibiting signs of depression, so fluoxetine is not indicated.

Question 59.    
A nurse working at an outpatient mental health center primarily with chronically mentally ill clients receives a telephone call from the mother of a client who lives at home. The mother reports that the client has not been taking her medication and now is refusing to go to the work center where she has worked for the past year. What should the nurse do first?
(a) Call the director of the work center for information about the client.
(b) Reserve an inpatient bed in preparation for the client’s admission.
(c) Ask to speak to the client directly on the phone.
(d) Make an appointment for the client to see the health care provider (HCP).
Answer:
(c) Ask to speak to the client directly on the phone.

Explanation:
The first thing that the nurse should do is to speak with the client on the phone and question her about perceptions or reasons that are interfering with her going to the sheltered workshop. This conveys that the nurse is interested and willing to help the client. The nurse should call the director of the work center for information only if the nurse receives the client’s permission. 

Making preparations for the client’s admission is inappropriate and would not be done until the client’s needs have been assessed and it is determined that the client requires hospitalization. Making an appointment with the HCP Q is inappropriate until the nurse has assessed the client’s needs.

Question 60.    
A nurse is teaching the families of clients with chronic mental illnesses about causes of relapse and rehospitalization. What should the nurse include as the primary cause?
(a) loss of family support 
(b) noncompliance with medications 
(c) sudden changes in medications 
(d) nonattendance at treatment programs
Answer:
(b) noncompliance with medications 

Explanation:
Noncompliance with medications is documented as the primary cause of relapse. Although loss of family support, sudden changes in medications, and nonattendance at treatment programs may contribute to relapse, these factors are not as significant as medication noncompliance as causes of relapse.

Question 61.    
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?
(a) Make a home visit, and tell the client that if he does not return to the program, he will lose his place there.
(b) Ask the director to assign the client to another group when he returns to the program.
(c) Make an appointment to meet the client at the mental health center, and ask him about the situation.
(d) Arrange for the placement of the client in a skill training program.
Answer:
(c) Make an appointment to meet the client at the mental health center, and ask him about the situation.

Explanation:
The most therapeutic action at this time is for the nurse to make an appointment with the client at the mental health center to explore his feelings and behavior. Doing so acknowledges the client’s importance and makes him a partner in resolving the problem. The nurse needs to determine what is going on in the situation first, and then plan accordingly. Threatening the client with loss of the position, asking for a new assignment for the client, or arranging for the placement of the client in a skill training program is inappropriate and premature.

Question 62.    
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?
(a) “It’s important for you to go back on your medicines.”
(b) “I hear how difficult it must be to live with the changes caused by your illness.”
(c) “You’ll have to talk to your health care provider (HCP) about stopping your medications.”
(d) “Your buddies will understand that you can’t drink anymore.”
Answer:
(b) “I hear how difficult it must be to live with the changes caused by your illness.”

Explanation:
By acknowledging the difficulties of living with the illness, the nurse conveys empathy for the client’s feelings and opens up the lines of communication. Although it is important for the client to maintain compliance with medication therapy, telling the client that it is important to start taking them again or to talk with the HCP Q about stopping the medications ignores the underlying feelings of the client’s initial statements. Stating that the client’s buddies will understand may or may not be true. 

Question 63.
A 23-year-old client diagnosed with schizophrenia cheerfully announces, “My mom and I are so excited that I’m pregnant. She’s willing to help us take care of the baby too.” Which reason should cause the nurse to be concerned about this situation?
(a) The client did not say that the father of the baby was excited about this.
(b) The mother is not likely to provide enough help for what the client needs.
(c) Symptom management will be difficult in, early pregnancy without medications.
(d) The client will have difficulty financially supporting the baby.
Answer:
(c) Symptom management will be difficult in, early pregnancy without medications.

Explanation:
Because antipsychotic agents cross the placental barrier and can be teratogenic, they are to be avoided during pregnancy, especially during the first trimester. Later in the pregnancy, low doses of medications may be given if necessary. Although the degree of excitement by the father, the mother’s ability to provide help, and the client’s financial situation may or may not be of concern, the priority in this situation is the safety of the fetus and risks associated with the need for antipsychotic therapy.

Question 64. 
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]?
(a) WBC of 3,500
(b) hemoglobin of 11.9 g/dL [119 g/L]
(c) sodium level of 136 mEq/L [136 mmol/L]
(d) hyaline casts in the urinalysis
Answer:
(a) WBC of 3,500

Explanation:
A side effect of clozapine is leukopenia. A WBC count is drawn every week, and if it starts to drop, the HCP is notified. Slightly low hemoglobin levels or a normal sodium level is not significant. Hyaline casts occur because of protein in the urine, and a small amount is normally found in the urine, especially after exercise

Question 65.
A client is being discharged before complete stabilization of symptoms. When developing a discharge plan for this client, the nurse should ensure that the client will have which factor in place?
(a) more medical consultations after discharge
(b) monthly outpatient visits
(c) many coordinated services
(d) a caring and supportive family
Answer:
(c) many coordinated services

Explanation:
Many coordinated services are needed, including medication management, more frequent outpatient visits, day treatment, or some combination of these, to decrease the risk of relapse, which is common among chronically ill clients. Medical consultations (if needed) would be included in the coordinated services provided. Chronically mentally ill clients, who are discharged early before becoming truly stable, typically require more than monthly outpatient visits because of the high risk of relapse. A caring and supportive family is ideal for all clients but not always available.

Question 66.
Which facility would the nurse rank as the lowest priority to expand when developing a community-based service program for clients with chronic mental illnesses?
(a) partial hospitalization programs
(b) psychiatric home care
(c) residential services
(d) long-term hospitals
Answer:
(d) long-term hospitals

Explanation:
For a community-based program, the need for long-term hospitalization is least needed if the other services, such as partial hospitalization programs, psychiatric home care, and residential services, are available and accessible.

Question 67.    
Crisis intervention plays a major role in the management of care for clients with chronic mental illnesses. Although the safety of the client and oth¬ers is always a priority, these clients typically need crisis intervention in which situations? Select all that apply.
(a) inability to keep outpatient appointments
(b) signs of relapse and decompensation
(c) threat of eviction from housing
(d) unpaid bills and lack of food
(e) occasionally missing a dose of medication
Answer:
(b) signs of relapse and decompensation
(c) threat of eviction from housing
(d) unpaid bills and lack of food

Explanation:
(b), (c), (d) Although all of the situations require immediate attention, the inability to keep outpatient appointments is less critical than signs of relapse and decompensation, threat of eviction, and unpaid bills and lack of food. Occasionally missing a dose of medication usually will not precipitate a crisis for a client.

Question 68.    
The most common reason given by mentally ill clients for noncompliance with medications is their uncomfortable adverse effects. When teaching the families, what need should the nurse identify as
the greatest?
(a) alternative ways to manage the adverse effects
(b) home visits to set up a week’s supply of medications
(c) family monitoring of the administration of medication
(d) outpatient monitoring of medication compliance
Answer:
(a) alternative ways to manage the adverse effects

Explanation:
Providing ways to decrease or manage adverse effects without additional medications is crucial. Although home visits, family monitoring, and outpatient monitoring may help, if the adverse effects are not controlled, the client is less likely to take the drug, which would interfere with its effectiveness.

Question 69.    
The stigma related to having a mental illness, especially a chronic illness, persists despite improvements in the management of illnesses and an increase in public education. Which view most perpetuates the stigma?
(a) Mental illness is hereditary.
(b) Mental illnesses have biochemical bases.
(c) Clients cannot prevent mental illness if they want to do so.
(d) Clients can recover from mental illness if they have willpower.
Answer:
(d) Clients can recover from mental illness if they have willpower.

Explanation:
Many still believe that recovery from mental illness is a matter of willpower for example, “pull yourself up by your bootstraps” or “just get over it.” This belief persists despite awareness that mental illness can be hereditary and has a biochemical basis. Mental illness can be prevented only if there is early intervention. Clients cannot prevent it just by the desire to do so.

Question 70.    
An older adult experiences short-term memory problems and occasional disorientation a few weeks after her husband’s death. She also is not sleeping, has urinary frequency and burning, and sees rats in the kitchen. The home care nurse calls the woman’s health care provider to discuss the client’s situation and background, assess, and give recommendations. The nurse concludes that the client most likely has which problem?
(a) the onset of Alzheimer’s disease
(b) trouble adjusting to living alone without her husband
(c) delayed grieving related to her Alzheimer’s disease
(d) delirium and a urinary tract infection (UTI)
Answer:
(d) delirium and a urinary tract infection (UTI)

Explanation:
Delirium is commonly due to a medical condition such as a UTI in the older adult. Delirium often involves memory problems, disorientation, and hallucinations. It develops rather quickly. There are not enough data to suggest Alzheimer’s disease especially given the quick onset of symptoms. Delayed grieving and adjusting to being alone are unlikely to cause hallucinations.

Question 71.    
An older adult client was prescribed loraze- pam 1 mg three times a day to help calm her anxiety after her husband’s death. The next day, the client calls her daughter asking when she is picking her up to go to the graveside. The client says she has been walking up and down the driveway for the past hour waiting for her daughter. Noting the client’s agitation, hyperactivity, and insistence, the daughter calls the nurse to report her mother’s behavior. Which finding would the nurse suspect as the cause of the mother’s behavior, and what action would she suggest?
(a) The client is manic and may need a sleeping pill.
(b) The client is experiencing a medication interaction and should go to the emergency department.
(c) The client is experiencing a paradoxical reaction to the lorazepam and should stop the new medication immediately.
(d) The client is overcome by grief and probably needs an antidepressant.
Answer:
(c) The client is experiencing a paradoxical reaction to the lorazepam and should stop the new medication immediately.

Explanation:
Paradoxical responses to benzodiazepines are more common in children and the older adult than other age groups and generally occur at the beginning of treatment. Grief and depression in the older adult is more likely to result in fatigue and withdrawal than hyperactivity and agitation. Treatment with a sleeping medication chemically related to the benzodiazepines is likely to result in an increase rather than decrease in agitation symptoms in older adult clients. A medication interaction is possible, but it less likely because most pharmacies screen for drug interactions when filling prescriptions.

Question 72 . 
The son of an older adult client who has cognitive impairments approaches the nurse and says, “I’m so upset. The health care provider says I have 4 days to decide on where my dad is going to live.” The nurse responds to the son’s concerns, gives him a list of types of living arrangements, and discusses the needs, abilities, and limitations of the client. The nurse should intervene further if the son makes which comment?
(a) “Boy, I have a lot to think about before I see the social worker tomorrow.”
(b) “I think I can handle most of Dad’s needs with the help of some home health care.”
(c) “I’m so afraid of making the wrong decision, but I can move him later if I need to.”
(d) "I want the social worker to make this decision so Dad won’t blame me.”
Answer:
(d) "I want the social worker to make this decision so Dad won’t blame me.”

Explanation:
Expecting the social worker to make the decision indicates that the son is avoiding participating in decisions about his father. The other responses convey that the son understands the importance of a careful decision, the availability of resources, and the ability to make new plans if needed.

Question 73.    
A client has been transferred to the hospital’s psychiatric unit from a nursing home for increasing confusion. The client’s behavior is found to be the result of cerebral arteriosclerosis. Which nursing staff actions should positively influence the client’s behavior? Select all that apply.
(a) limiting the client’s choices
(b) accepting the client as he is
(c) allowing the client to do as he wishes
(d) acting nonchalantly
(e) explaining to the client what he needs to do step-by-step
Answer:
(a) limiting the client’s choices
(b) accepting the client as he is
(e) explaining to the client what he needs to do step-by-step

Explanation:
(a), (b), (e) Confused clients need fewer choices, acceptance as a person, and step-by-step directions. Allowing the client to do as he wishes can lead to substandard care and the risk of harm. Acting nonchalantly conveys a lack of caring.

Question 74.    
The nurse observes a client in a group who is reminiscing about his past. Which effect should the nurse expect reminiscing to have on the client’s functioning in the hospital?
(a) Increase the client’s confusion and disorientation.
(b) Cause the client to become sad.
(c) Decrease the client’s feelings of isolation and loneliness.
(d) Keep the client from participating in therapeutic activities.
Answer:
(c) Decrease the client’s feelings of isolation and loneliness.

Explanation:
Reminiscing can help reduce depression in an older adult client and lessens feelings of isolation and loneliness. Reminiscing encourages a focus on positive memories and accomplishments as well as shared memories with other clients. An increase in confusion and disorientation is most likely the result of other cognitive and situational factors, such as loss of short-term memory, not reminiscing. The client will not likely become sad because reminiscing helps the client connect with positive memories. Keeping the client from participating in therapeutic activities is less likely with reminiscing.

Question 75.    
An older adult client is admitted and diagnosed with delirium. Later in the day, he tries to get out of the locked unit. He yells, “Unlock this door. I’ve got to go see my doctor. I just can’t miss my monthly Friday appointment.” Which of the following responses by the nurse is most appropriate?
(a) “Please come away from the door. I’ll show you your room.”
(b) “It’s 5 o’clock Tuesday, and you’re in the hospital. I’m Anne, a nurse.”
(c) “The door is locked to keep you from getting lost.”
(d) “I want you to come eat your lunch before you go for your appointment.”
Answer:
(b) “It’s 5 o’clock Tuesday, and you’re in the hospital. I’m Anne, a nurse.”

Explanation:
Loss of orientation, especially for time and place, is common in delirium. The nurse should orient the client by telling him the time, date, place, and who the client is with. Taking the client to his room and telling him why the door is locked do not address his disorientation. Telling the client to eat before going to his medical appointment reinforces his disorientation.

Question 76.    
An older adult client is admitted to the unit after being examined in the emergency department (ED) and diagnosed with delirium. After the admission interviews with the client and her grandson, the nurse explains that there will be more laboratory tests and X-rays done that day. The grandson says, “She’s already been stuck several times and had a brain scan or something. Just give her some medicine and let her rest. ” What should the nurse tell the grandson? Select all that apply.
(a) “I agree she needs to rest, but there’s no one specific medicine for your grandmother’s condition.”
(b) “The health care provider will look at the results of those tests in the ED and decide what other tests are needed.”
(c) “Delirium commonly results from underlying medical causes that we need to identify and correct.”
(d) “Tell me about your grandmother’s behaviors, and maybe I could figure out what medicine she needs.”
(e) “I’ll ask the health care provider to postpone more tests until tomorrow.” 
Answer:
(a) “I agree she needs to rest, but there’s no one specific medicine for your grandmother’s condition.”
(b) “The health care provider will look at the results of those tests in the ED and decide what other tests are needed.”
(c) “Delirium commonly results from underlying medical causes that we need to identify and correct.”

Explanation:
(a), (b), (c) The client does need rest, and it is true that there is no specific medicine for delirium, but it is crucial to identify and treat the underlying causes of delirium. Other tests will be based on the results of already completed tests. Although some medications may be prescribed to help the client with her behaviors, this is not the primary basis for medication prescriptions. 

Because the underlying medical causes of delirium could be fatal, treatment must be initiated as soon as possible. It is not the nurse’s role to determine medications for this client. Postponing tests until the next day is inappropriate.

Question 77.    
The nurse attempts to draw blood from a client with a diagnosis of delirium who was admitted last evening. The client yells out, “Stop Leave me alone! What are you trying to do to me? What’s happening to me?” Which response by the nurse is most appropriate?
(a) “The tests of your blood will help us figure out what’s happening to you.”
(b) “Please hold still so I don’t have to stick you a second time.”
(c) “After I get your blood, I’ll get some medicine to help you calm down.”
(d) “I’ll tell you everything after I get your blood tests to the laboratory.”
Answer:
(a) “The tests of your blood will help us figure out what’s happening to you.”

Explanation:
Explaining why blood is being taken responds to the client’s concerns or fears about what is happening. Threatening more pain or promising to explain later ignores or postpones meeting the client’s need for information. The client’s statements do not reflect loss of self-control requiring medication intervention.

Question 78.    
An older adult client diagnosed with major depression is suddenly experiencing sleep disturbances, inability to focus, poor recent memory, altered perceptions, and disorientation to time and place. Lab results indicate the client has a urinary tract infection (UTI) and dehydration. After explaining the situation and giving the background and assessment data, the nurse should make which rec-ommendation to the client’s health care provider?
(a) a prescription to place the client in restraints
(b) a reevaluation of the client’s mental status
(c) the transfer of the client to a medical unit
(d) a transfer of the client to a nursing home
Answer:
(c) the transfer of the client to a medical unit

Explanation:
The client is showing symptoms of delirium, a common outcome of UTI in older adults. The nurse can request a transfer to a medical unit for acute medical intervention. The client’s symptoms are not just due to a worsening of the depression. There are not indications that the client needs restraints or a transfer to a nursing home at this point.

Question 79.    
When caring for the client diagnosed with delirium, the nurse should investigate which condition as the most important?
(a) cancer of any kind
(b) impaired hearing
(c) prescription drug intoxication
(d) heart failure
Answer:
(c) prescription drug intoxication

Explanation:
Polypharmacy is much more common in the older adult. Drug interactions increase the incidence of intoxication from prescribed medications, especially with combinations of analgesics, digoxin, diuretics, and anticholinergics. With drug intoxication, the onset of the delirium typically is quick. Although cancer, impaired hearing, and heart failure could lead to delirium in the older adult, the onset would be more gradual.

Question 80.    
Which characteristic would make the nurse suspect that a client with changes in cognition has delirium?
(a) disturbances in cognition and consciousness that fluctuate during the day
(b) the failure to identify objects despite intact sensory functions
(c) significant impairment in social or occupational functioning over time
(d) memory impairment to the degree of being called amnesia
Answer:
(a) disturbances in cognition and consciousness that fluctuate during the day

Explanation:
In addition to developing over a period of hours or days, fluctuating symptoms are characteristic of delirium. The failure to identify objects despite intact sensory functions, significant impairment in social or occupational functioning over time, and memory impairment to the degree of being called amnesia all indicate dementia.

Question 81. 
What intervention is essential when caring for a client who is experiencing delirium?
(a) controlling behavioral symptoms with low-dose psychotropics
(b) identifying the underlying causative condition or illness
(c) manipulating the environment to increase orientation
(d) decreasing or discontinuing all previously prescribed medications
Answer:
(b) identifying the underlying causative condition or illness

Explanation:
The most critical aspect of caring for the client with delirium is to institute measures to correct the underlying causative condition or illness. Controlling behavioral symptoms with low-dose psychotropics, manipulating the environment, and decreasing or discontinuing all medications may be dangerous to the client’s health. 

Question 82.
What is a realistic short-term goal to be accomplished in 2 to 3 days for a client with delirium?
(a) Explain the experience of having delirium.
(b) Resume a normal sleep-wake cycle.
(c) Regain orientation to time and place.
(d) Establish normal bowel and bladder function.
Answer:
(c) Regain orientation to time and place.

Explanation:
In approximately 2 to 3 days, the client should be able to regain orientation and thus become oriented to time and place. Being able to explain the experience of having delirium is something that the client is expected to achieve later in the course of the illness, but ultimately before discharge. Resuming a normal sleep-wake cycle and establishing normal bowel and bladder function probably will take longer, depending on how long it takes to resolve the underlying condition.

Question 83.    
What should the nurse expect to include as a priority in the plan of care for a client with delirium based on the nurse’s understanding of the disturbances in orientation associated with this disorder?
(a) identifying self and making sure that the nurse has the client’s attention
(b) eliminating the client’s napping in the day time as much as possible
(c) engaging the client in reminiscing with relatives or visitors
(d) avoiding arguing with a suspicious client about his perceptions of reality
Answer:
(a) identifying self and making sure that the nurse has the client’s attention

Explanation:
Identifying oneself and making sure that the nurse has the client’s attention address the difficulties with focusing, orientation, and maintaining attention. Eliminating daytime napping is unrealistic until the cause of the delirium is determined and the client’s ability to focus and maintain attention improves. Engaging the client in reminiscing and avoiding arguing are also unrealistic at this time.

Question 84. 
A client has been in the critical care unit for 3 days following a severe myocardial infarction. Although he is medically stable, he has begun to have fluctuating episodes of consciousness, illogical thinking, and anxiety. He is picking at the air to “catch these baby angels flying around my head.” While waiting for medical and psychiatric consults, which needs have the highest priority? Select all that apply.
(a) decreasing as much abnormal stimuli as possible
(b) avoiding challenging the client’s perceptions about “baby angels”
(c) orienting the client about his medical condition
(d) gently presenting reality as needed
(e) calling the client’s family to report his onset of dementia
Answer:
(a) decreasing as much abnormal stimuli as possible
(b) avoiding challenging the client’s perceptions about “baby angels”
(d) gently presenting reality as needed

Explanation:
(a), (b), (d) The abnormal stimuli of the critical care unit can aggravate the symptoms of delirium. Arguing with hallucinations is inappropriate. When a client has illogical thinking, gently presenting reality is appropriate, but orienting the client to his condition is unlikely to be helpful. Dementia is not the likely cause of the client’s symptoms. The client is experiencing delirium, not dementia.

Question 85. 
The nurse is assessing an older adult for signs of dementia. The nurse gives the client three words to remember: “cat,” “crackers,” and “toys.” After having the client perform a short task, the nurse asks the client to repeat the words. The client says “toys,” “boys,” and “joys.” What should the nurse do next?
(a) Ask the client to repeat the original words one more time.
(b) Note on the medical record that the client has echolalia.
(c) Refer the client to a health care provider for further follow-up.
(d) Repeat the test when a family member is present.
Answer:
(c) Refer the client to a health care provider for further follow-up.

Explanation:
That the client is not able to recall the three words is a likely indicator of dementia; the nurse should make a referral for further testing. It is recommended not to repeat the test a second time if the client is not able to recall the words. Although the client repeated rhyming words, echolalia refers to repletion of the same word. It is not necessary to have a family member present when conducting the test, but the nurse should communicate the findings to the family and encourage them to seek follow-up assessment.

Question 86.    
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?
(a) impulsive acts of aggression
(b) sleep disturbance
(c) unable to recognize objects by touch
(d) difficulties with speech
Answer:
(a) impulsive acts of aggression

Explanation:
Impulsive acts of aggression and violence have been linked to dysregulation of the amygdala. The hypothalamus regulates basic human activities such as sleep-rest patterns. The parietal lobe contains the primary somatosensory area. The temporal lobes contain the primary auditory areas.

Question 87.    
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 which problem?
(a) dementia
(b) depression
(c) delirium
(d) dehydration
Answer:
(c) delirium

Explanation:
Based on CAM’s assessment tool, the client has an acute onset of behaviors, is inattentive, has disorganized thinking, and is lethargic (decreased level of consciousness). This cluster of behaviors constitutes delirium. Dementia has a slow onset, the client’s level of consciousness is usually normal, and the client can focus attention. Clients who are depressed are alert and oriented and able to focus attention, although they may be easily distracted. Further assessment is needed to determine if the client also is dehydrated.

Question 88.    
A nurse on the geropsychiatric unit receives a call from the son of a recently discharged client. He reports that his father just got a prescription for memantine to take “on top of his donepezil.” The son then asks, “Why does he have to take extra medicines?” What should the nurse tell the son?
(a) “Maybe the donepezil alone is not improving his dementia fast enough or well enough.”
(b) “Memantine and donepezil are commonly used together to slow the progression of dementia.”
(c) “Memantine is more effective than donepezil. Your father will be tapered off the donepezil.”
(d) “Donepezil has a short half-life, and memantine has a long half-life. They work well together.”
Answer:
(b) “Memantine and donepezil are commonly used together to slow the progression of dementia.”

Explanation:
Memantine and donepezil are commonly given together. Neither medicine will improve dementia, but they may slow the progression. Neither medicine is more effective than the other; they act differently in the brain. Both medicines have a half-life of 60 or more hours.

Question 89. 
An older adult diagnosed with dementia wanders the halls of the locked nursing unit during the day. To ensure the client’s safety while walking in the halls, what should the nurse do?
(a) Administer PRN haloperidol to decrease the need to walk.
(b) Assess the client’s gait for steadiness.
(c) Restrain the client in a geriatric chair.
(d) Administer PRN lorazepam to providesedation.
Answer:
(b) Assess the client’s gait for steadiness.

Explanation:
Older adult clients with dementia have increased risk for falls due to balance problems, medication use, and decreased eyesight. Haloperidol may cause extrapyramidal side effects, which increase the risk for falls. The client is not agitated, so restraints are not indicated. Lorazepam may increase fall risk and cause paradoxical excitement

Question 90.    
A client with dementia who prefers to stay in his room has been brought to the dayroom. After 10 minutes, the client becomes agitated and retreats to his room again. The nurse decides to assess the conditions in the dayroom. Which is the most likely occurrence that is disturbing to this client?
(a) There is only one other client in the dayroom the rest are in a group session in another room.
(b) There are three staff members and one health care provider (HCP) in the nurse’s station working on charting.
(c) A relaxation tape is playing in one corner of the room, and a television airing a special on crime is playing in the opposite corner.
(d) A housekeeping staff member is washing off the countertops in the kitchen, which is on the far side of the dayroom.
Answer:
(c) A relaxation tape is playing in one corner of the room, and a television airing a special on crime is playing in the opposite corner.

Explanation:
The tape and television are competing, even conflicting, stimuli. Crime events portrayed on television could be misperceived as a real threat to the client. A low number of clients and the presence of a few staff members quietly working are less intense stimuli for the client and not likely to be disturbing.

Question 91.    
Nursing staff are trying to provide for the safety of an older adult with moderate dementia. The client is wandering at night and has trouble keeping her balance. She has fallen twice but has had no resulting injuries. Which action by the nurse is most appropriate?
(a) Move the client to a room near the nurse’s station and install a bed alarm.
(b) Have the client sleep in a reclining chair across from the nurse’s station.
(c) Help the client to bed and raise all four bedrails.
(d) Ask a family member to stay with the client at night.
Answer:
(a) Move the client to a room near the nurse’s station and install a bed alarm.

Explanation:
Using a bed alarm enables the staff to respond immediately if the client tries to get out of bed. Sleeping in a chair at the nurse’s station interferes with the client’s restful sleep and privacy. Using all four bedrails is considered a restraint and unsafe practice. It is not appropriate to expect a family member to stay all night with the client.

Question 92.    
During a home visit to an older adult with mild dementia, the client’s daughter reports that she has one major problem with her mother. She says, “She sleeps most of the day and is up most of the night. I can’t get a decent night’s sleep anymore.” Which suggestions should the nurse make to the daughter? Select all that apply.
(a) Ask the client’s health care provider for a strong sleep medicine.
(b) Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime.
(c) Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day.
(d) Promote relaxation before bedtime with a warm bath or relaxing music.
(e) Have the daughter encourage the use of caffeinated beverages during the day to keep her mother awake.
Answer:
(b) Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime.
(c) Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day.
(d) Promote relaxation before bedtime with a warm bath or relaxing music.

Explanation:
(b), (c), (d) A set routine and brief exercises help decrease daytime sleeping. Decreasing caffeine and fluids and promoting relaxation at bedtime promote nighttime sleeping. A strong sleep medicine for an older adult client is contraindicated due to changes in metabolism, increased adverse effects, and the risk of falls. Using caffeinated beverages may stimulate metabolism but can also have long-lasting adverse effects and may prevent sleep at bedtime.

Question 93.    
An older adult client with moderate dementia is being admitted to the memory wing of an assisted living unit. When the family brings the personal belongings of the client, the nurse should warn against leaving which item into the unit?
(a) a clear cookie jar
(b) several pants suits
(c) word-find books
(d) a pair of sewing scissors
Answer:
(d) a pair of sewing scissors

Explanation:
Clients entering a memory unit will wear a “wander guard” type of detector, most likely on a wrist or ankle. When the client wanders off the unit, the detector will alarm. A pair of scissors could be used to cut the detector off allowing the client to wander past the alarm and escape from the protected surroundings. A clear cookie jar allows the client to have home-like items such as treats for visitors, family, etc., and serve as a reminder of where these items are in their home surroundings. Clothing from home is appropriate to bring to the memory assisted living unit. Word-find books would be appropriate for the client in this area.

Question 94.    
A client with early dementia exhibits disturbances in mental awareness and orientation to reality. The nurse should expect to assess a loss of ability in what other areas?
(a) speech
(b) judgment
(c) endurance
(d) balance
Answer:
(b) judgment

Explanation:
Clients with chronic cognitive disorders experience defects in memory orientation and intellectual functions, such as judgment and discrimination. Loss of other abilities, such as speech, endurance, and balance, is less typical.

Question 95.    
The client with dementia states to the nurse, “I know you. You’re Margaret, the girl who lives down the street from me.” Which response by the nurse is most therapeutic?
(a) “Mrs. Jones, I’m Rachel, a nurse here at the hospital.”
(b) “Now Mrs. Jones, you know who I am.”
(c) “Mrs. Jones, I told you already, I’m Rachel, and I don’t live down the street.”
(d) “I think you forgot that I’m Rachel, Mrs. Jones.”
Answer:
(a) “Mrs. Jones, I’m Rachel, a nurse here at the hospital.”

Explanation:
Because of the client’s short-term memory impairment, the nurse gently corrects the client by stating her name and who she is. This approach decreases anxiety, embarrassment, and shame and maintains the client’s self-esteem. Telling the client that she knows who the nurse is or that she forgot can elicit feelings of embarrassment and shame. Saying “I told you already” sounds condescending, as if blaming the client for not remembering.

Question 96.    
While assessing a client diagnosed with dementia, the nurse notes that her husband is concerned about what he should do when she uses vulgar language with him. What should the nurse tell the husband?
(a) Tell her that she is very rude.
(b) Ignore the vulgarity and distract her.
(c) Tell her to stop swearing immediately.
(d) Say nothing and leave the room.
Answer:
(b) Ignore the vulgarity and distract her.

Explanation:
Vulgar language is common in clients with dementia when they are having trouble communicating about a topic. Ignoring the vulgarity and distracting her is appropriate. Telling the client she is rude or to stop swearing will have no lasting effect and may cause agitation. Just leaving the room is abandonment that the client will not understand.

Question 97.    
The nurse understands that the client with severe dementia and motor apraxia may be able to perform which action?
(a) Balance a checkbook accurately.
(b) Brush the teeth when handed a toothbrush.
(c) Use confabulation when telling a story.
(d) Find misplaced car keys.
Answer:
(b) Brush the teeth when handed a toothbrush.

Explanation:
Highly conditioned motor skills, such as brushing teeth, may be retained by the client who has dementia and motor apraxia. Balancing a checkbook involves calculations, a complex skill that is lost with severe dementia. Confabulation is fabrication of details to fill a memory gap. This is more common when the client is aware of a memory problem, not when dementia is severe. Finding keys is a memory factor, not a motor function.

Question 98. 
When communicating with the client who is experiencing dementia and exhibiting decreased attention and increased confusion, which interven¬tion should the nurse employ as the first step?
(a) using gentle touch to convey empathy
(b) rephrasing questions the client does not understand
(c) eliminating distracting stimuli such as turning off the television
(d) asking the client to go for a walk while talking
Answer:
(c) eliminating distracting stimuli such as turning off the television

Explanation:
Competing and excessive stimuli lead to sensory overload and confusion. Therefore, the nurse should first eliminate any distracting stimuli. After this is accomplished, then using touch and rephras-ing questions are appropriate. Going for a walk while talking has little benefit on attention and confusion

Question 99. 
During family teaching, the daughter of a client with dementia mentions to the nurse that her mother distorts things. The nurse understands that the daughter needs further teaching about dementia when she makes which statement?
(a) “I tell her reality, such as ‘That noise is the wind in the trees.’”
(b) “I understand the misperceptions are part of the disease.”
(c) "I turn off the radio when we’re in another room.”
(d) “I tell her she’s wrong, and then I tell her what’s right.”
Answer:
(d) “I tell her she’s wrong, and then I tell her what’s right.”

Explanation:
Telling the client that she is wrong and then telling her what is right is argumentative and challenging. Arguing with or challenging distortions is least effective because it increases defensiveness. Telling the client about reality indicates awareness of the issues and is appropriate. Acknowledging that misperceptions are part of the disease indicates an understanding of the disease and an awareness of the issues. Turning off the radio helps to limit environmental stimuli and indicates an awareness of the issues.

Question 100. 
The client in the early stage of Alzheimer’s disease and his adult son attend an appointment at the community mental health center. While conversing with the nurse, the son states, “I’m tired of hearing about how things were 30 years ago. Why does Dad always talk about the past?” What should the nurse tell the son?
(a) “Your dad lost his short-term memory, but he still has his long-term memory.”
(b) “You need to be more accepting of your dad’s behavior.”
(c) “I want you to understand your dad’s level of anxiety.”
(d) “Reminding your dad that you have heard that story will help him stop.”
Answer:
(a) “Your dad lost his short-term memory, but he still has his long-term memory.”

Explanation:
The son’s statements regarding his father’s recalling past events is typical for family members of clients in the early stage of Alzheimer’s disease, when recent memory is impaired. Telling the son to be more accepting is being critical and not an attempt to educate. Understanding the client’s level of anxiety is unrelated to the memory loss of Alzheimer’s disease. The client cannot stop remi-niscing at will.

Question 101.    
The nurse discusses the possibility of a client’s attending day treatment for clients with early Alzheimer’s disease. What is the best rationale for encouraging day treatment?
(a) The client would have more structure to his day.
(b) The staff are excellent in the treatment they offer clients.
(c) The client would benefit from increased social interaction.
(d) The family would have more time to engage in their daily activities.
Answer:
(c) The client would benefit from increased social interaction.

Explanation:
The best rationale for day treatment for the client with Alzheimer’s disease is the enhancement of social interactions. More daily structure, excel¬lent staff, and allowing caregivers more time for themselves are all positive aspects, but they are less focused on the client’s needs.

Question 102. 
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?
(a) Perform activities for the client during hospitalization.
(b) Document all activities the nurse expects the client to complete during the shift.
(c) Inform the client that if morning care is not completed by 0830 hours, the UAP will complete it.
(d) Encourage the client to complete as many activities as possible, and provide ample time to complete them.
Answer:
(d) Encourage the client to complete as many activities as possible, and provide ample time to complete them.

Explanation:
By fostering independence and providing as much time as possible, the nurse is helping the client to continue to complete as many tasks as possible. Performing activities for the client is counter-productive. A list may cause the client to become frustrated if the list is not completed or if it becomes lost. Informing the client that the UAP [Q] will complete activities may be perceived as a threat.

Question 103. 
The family of a client diagnosed with Alzheimer’s disease wants to keep the client at home. They say that they have the most difficulty in managing his wandering. What should the nurse instruct the family to do? Select all that apply.
(a) Ask the health care provider (HCP) for a sleeping medication.
(b) Install motion and sound detectors.
(c) Have a relative sit with the client all night.
(d) Have the client wear a medical alert bracelet.
(e) Install door alarms and high door locks.
Answer:
(b) Install motion and sound detectors.
(d) Have the client wear a medical alert bracelet.
(e) Install door alarms and high door locks.

Explanation:
(b), (d), (e) Motion and sound detectors, a Medical Alert bracelet, and door alarms and locks are all appropriate interventions for wandering. Sleep medications do not prevent wandering before and after the client is asleep and may have negative effects. Having a relative sit with the client is usu-ally an unrealistic burden.

Question 104.    
What is a priority to include in the plan of care for a client with Alzheimer’s disease who is experiencing difficulty processing and completing complex tasks?
(a) repeating the directions until the client follows them
(b) asking the client to do one step of the task at a time
(c) demonstrating for the client how to do the task
(d) maintaining routine and structure for the client
Answer:
(b) asking the client to do one step of the task at a time

Explanation:
Because the client is experiencing difficulty processing and completing complex tasks, the priority is to provide the client with only one step at a time, thereby breaking the task up into simple steps, ones that the client can process. Repeating the directions until the client follows them or demon-strating how to do the task is still too overwhelming to the client because of the multiple steps involved. Although maintaining structure and routine is important, it is unrelated to task completion.

Question 105.    
During a home visit, a client who is 75 years of age tells the nurse, "Lately I’m getting forgetful about things. For one thing, I can’t remember names. Do you think I’m getting Alzheimer’s disease?” Which response by the nurse is the most therapeutic?
(a) "It’s normal for people your age to forget things such as names.”
(b) “I do the same thing. Sometimes, I can’t remember someone’s name either.”
(c) “Tell me more about your forgetfulness. It’s not unusual for forgetfulness to occur.”
(d) “Most people your age have this problem. It’s not Alzheimer’s disease.”
Answer:
(c) “Tell me more about your forgetfulness. It’s not unusual for forgetfulness to occur.”

Explanation:
The therapeutic communication technique of asking the client to describe the forgetfulness seeks clarification and provides the client an opportunity to tell more about the problem. A client who is 75 years of age may take a prolonged time to remember as a result of normal cognitive changes of aging, but telling the client it is normal to forget is diminishing the importance of the comment. 

Referring to the nurse’s self is also diminishing the importance of the client’s concern. It is not the nurse’s role to indicate that the client does or does not have Alzheimer’s disease; the nurse uses communication techniques that obtain sufficient information to determine if a referral is needed.

Question 106.    
When helping the families of clients with Alzheimer’s disease cope with vulgar or sexual behaviors, which suggestion is most helpful?
(a) Ignore the behaviors, but try to identify the underlying need for the behaviors.
(b) Give feedback on the inappropriateness of the behaviors.
(c) Employ anger management strategies.
(d) Administer the prescribed risperidone.
Answer:
(a) Ignore the behaviors, but try to identify the underlying need for the behaviors.

Explanation:
The vulgar or sexual behaviors are commonly expressions of anger or more sensual needs that can be addressed directly. Therefore, the families should be encouraged to ignore the behaviors but attempt to identify their purpose. Then the purpose can be addressed, possibly leading to a decrease in the behaviors.

Because of impaired cognitive function, the client is not likely to be able to process the inappropriateness of the behaviors if given feedback. Likewise, anger management strategies would be ineffective because the client would probably be unable to process the inappropriateness of the behaviors. Risperidone may decrease agita-tion, but it does not improve social behaviors.

Question 107.    
The nurse determines that the son of a client with Alzheimer’s disease needs further education about the disease when he makes which statement?
(a) “I didn’t realize the deterioration would be so incapacitating.”
(b) “The Alzheimer’s support group has so much good information.”
(c) “I get tired of the same old stories, but I know it’s important for Dad.”
(d) “I woke up this morning expecting that my old Dad would be back.”
Answer:
(d) “I woke up this morning expecting that my old Dad would be back.”

Explanation:
The statement about expecting that the old Dad would be back conveys a lack of acceptance of the irreversible nature of the disease. The statement about not realizing that the deterioration would be so incapacitating is based in reality. The statement about the Alzheimer’s group is based in reality and demonstrates the son’s involvement with managing the disease. Stating that reminiscing is important reflects a realistic interpretation on the son’s part.

Question 108.    
The husband of a client who was diagnosed 6 years ago with Alzheimer’s disease approaches the nurse and says, “I’m so excited that my wife is starting to use donepezil for her illness.” What should the nurse tell the husband?
(a) The medication is effective mostly in the early stages of the illness.
(b) The adverse effects of the drug are numerous.
(c) The client will attain a functional level equal to that of that of 6 years ago.
(d) Effectiveness in the terminal phase of the illness is scientifically proven.
Answer:
(c) The client will attain a functional level equal to that of that of 6 years ago.

Explanation:
When compared with other similar medications, donepezil has fewer adverse effects. Donepezil is effective primarily in the early stages of the disease. The drug helps to slow the progression of the disease if started in the early stages. After the client has been diagnosed for 6 years, improvement to the level seen 6 years ago is highly unlikely. Data are not available to support the drug’s effectiveness for clients in the terminal phase of the disease.

Question 109.    
The health care provider prescribes risperidone for a client with Alzheimer’s disease. The nurse anticipates administering this medication to help decrease which behavior?
(a) sleep disturbances
(b) concomitant depression
(c) agitation and aggression
(d) confusion and withdrawal
Answer:
(c) agitation and aggression

Explanation:
Antip sychotics are most effective with agitation and aggression. Antipsychotics have little effect on sleep disturbances, concomitant depression, or confusion and withdrawal.

Question 110.    
The nurse makes a home visit with a client diagnosed with Alzheimer’s disease. The client is recently started on lorazepam due to increased anxiety. The nurse is cautioning the family about the use of lorazepam. The nurse should instruct the family to report which significant side effect to the health care provider?
(a) paradoxical excitement
(b) headache
(c) slowing of reflexes
(d) fatigue
Answer:
(a) paradoxical excitement

Explanation:
Although all of the side effects listed are possible with lorazepam, paradoxical excitement is cause for immediate discontinuation of the medication. (Paradoxical excitement is the opposite reaction to lorazepam than is expected.) The other side effects tend to be minor and usually are transient.

Question 111.    
When providing family education for those who have a relative with Alzheimer’s disease about minimizing stress, which suggestion is most relevant?
(a) Allow the client to go to bed four to five times during the day.
(b) Test the cognitive functioning of the client several times a day.
(c) Provide reality orientation even if the memory loss is severe.
(d) Maintain consistency in environment, routine, and caregivers.
Answer:
(d) Maintain consistency in environment, routine, and caregivers.

Explanation:
Change increases stress. Therefore, the most important and relevant suggestion is to maintain consistency in the client’s environment, routine, and caregivers. Although rest periods are important, going to bed interferes with the sleep- wake cycle. Rest in a recliner chair is more useful. Testing cognitive functioning and reality orienta-tion are not likely to be successful and may increase stress if memory loss is severe.

Question 112.
An older adult client who has been diagnosed with delusional disorder for many years is exhibiting early symptoms of dementia. His daughter lives with him to help him manage daily activities, and he attends a day care program for seniors during the week while she works. A nurse at the day care center hears him say, “If my neighbor puts up a fence, I’ll blow him away with my shotgun. He has never respected my property line, and I’ve had it!” Which action should the nurse take?
(a) Observe the client more closely, but do not report his threat since he will likely not be able to follow through with it because of his dementia.
(b) Report the comment to the client’s daughter so she can observe him more closely, but refrain from telling the neighbor due to privacy regulations.
(c) Report the comment to the neighbor, the intended victim, but refrain from telling the daughter since she will just worry about actions of her father she cannot control.
(d) Report the comment to the neighbor, the daughter, and the police since there is the potential for a criminal act. 
Answer:
(d) Report the comment to the neighbor, the daughter, and the police since there is the potential for a criminal act. 

Explanation:
The neighbor could be harmed as well as the daughter if she should try to stop her father from using the gun, so both should be notified. Any use of firearms against another person requires the involvement of the police. The nurse has a legal/ ethical responsibility to warn potential victims and other involved parties as well as law enforcement authorities when one person makes a threat against another person. This duty supersedes confidentiality statutes. Failure to do so and to document it can result in civil penalties. The client’s early dementia would likely not prevent him from carrying through his threat.

Question 113.    
A client reports having blurred vision after 4 days of taking haloperidol 1 mg twice a day and benztropine 2 mg twice a day. The nurse contacts the health care provider to explain the situation, background, and assessment and make a recommendation. Which information reported to the HCP is the assessment of the situation?
(a) “Mr. Roberts is taking 1 mg of haloperidol twice a day and benztropine 2 mg twice a day.”
(b) “I think Mr. Roberts might need a lower dose of benztropine.”
(c) “Mr. Roberts reports having blurred vision since this morning.”
(d) “The higher dose of benztropine could be causing Mr. Roberts’ blurred vision.”
Answer:
(d) “The higher dose of benztropine could be causing Mr. Roberts’ blurred vision.”

Explanation:
Benztropine has a common side effect of blurred vision. After evaluating the relative doses of haloperidol and benztropine, the assessment would be that the higher dose of benztropine compared to the dose of haloperidol is responsible for the blurred vision. (High doses of haloperidol can cause blurred vision at times.) Reporting that Mr. Roberts has blurred vision is the situation. Listing the medi-cations and doses is describing the background. The recommendation would be a lower dose of benztropine.

Question 114.    
What should be charted by the nurse when the client has an involuntary commitment or formal admission status?
(a) Nothing should be charted. The forms are in the chart; there is no need to duplicate.
(b) The client’s receipt of information about status and rights should be charted.
(c) The client’s willingness to cooperate with seclusion should be charted.
(d) The name of the health care provider (HCP) officially signing the certificates should be charted.
Answer:
(b) The client’s receipt of information about status and rights should be charted.

Explanation:
Nurses are required to document that clients have been given information about their status and rights. Seclusion is not related to people becoming involuntary or certified clients. Including details contained within the certificates, such as an HCP signing the certificates, is not required.

Question 115.
When assessing an aggressive client, which behavior warrants the nurse’s prompt reporting and use of safety precautions?
(a) crying when talking about his divorce
(b) starting a petition to delay bedtime
(c) declining attendance at a daily group therapy session
(d) naming another client as his adversary
Answer:
(d) naming another client as his adversary

Explanation:
The client exhibits aggression against his perceived adversary when he names another client as his adversary. The staff will need to watch him carefully for signs of impending violent behavior that may injure others. Crying about a divorce would be appropriate, not pathologic, behavior demonstrating grief over a loss. A petition to delay bedtime would be a positive, direct action aimed at a bothersome situation. Although declining to attend group therapy needs follow-up, there may be any number of unknown reasons for this action.

Question 116.    
A nurse plans care for an older adult client with cognitive impairment who is still living at home. Which action should the nurse identify as a priority for safety in planning care for this client?
(a) having two people accompany the client whenever the client is up and about
(b) ensuring the removal of objects in the client’s path that may cause him to trip
(c) putting the client’s favorite belongings in a safe place so that he will not lose them
(d) giving the client his medications in liquid form to make certain that he swallows them
Answer:
(b) ensuring the removal of objects in the client’s path that may cause him to trip

Explanation:
When caring for a client with cognitive impairment, the priority is to ensure that all objects in the client’s path are removed to prevent the client from falling. Additional measures, such as having two people accompany the client when he ambulates, placing his favorite things in safekeeping, and giving medications in a liquid form to be sure he swallows them, are less crucial.

Question 117.    
The nurse manager of a psychiatric unit notices that one of the nurses commonly avoids a 75-year-old client’s company. Which factor should the nurse manager identify as being the most likely cause of this nurse’s discomfort with older clients?
(a) fears and conflicts about aging
(b) dislike of physical contact with older people
(c) a desire to be surrounded by beauty and youth
(d) recent experiences with her mother’s older adult friends
Answer:
(a) fears and conflicts about aging 

Explanation:
The most common reason for the nurse’s discomfort with older adult clients is that she has not examined her own fears and conflicts about aging. Until nurses resolve their fears, it is unlikely that they will feel comfortable with older adult clients. A dislike of physical contact with older people, a desire to be surrounded by beauty and youth, and recent experiences with a parent’s older adult friends are possible explanations, but not common or likely.