A client with delusional thinking shows a lack of interest in eating at meal times. She states that she is unworthy of eating and that her children will die if she eats. Which nursing action would be most appropriate for this client?
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Solution
Restricting the client’s access to food except at specified meal and snack times
Option C: Restricting access to food except at specified times prevents the client from eating when she feels anxious, guilty, or depressed; this, in turn, decreases the association between these emotions and food.
Option A: Telling the client she may become sick or die may reinforce her behavior because illness or death may be her goal.
Option B: Paying special attention to rituals and emotions associated with meals also would reinforce undesirable behavior.
Option D: Encouraging the client to express feelings at meal times would increase the association between emotions and food; instead, the nurse should encourage her to express feelings at other times.
A client with schizophrenia hears a voice telling him he is evil and must die. The nurse understands that the client is experiencing:
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Solution
a hallucination.
Option D: A hallucination is a sensory perception, such as hearing voices and seeing objects, that only the client experiences.
Option A: A delusion is a false belief.
Option B: Flight of ideas refers to a speech pattern in which the client skips from one unrelated subject to another.
Option C: Ideas of reference refers to the mistaken belief that someone or something outside the client is controlling the client’s ideas or behavior.
The nurse formulates a nursing diagnosis of Impaired social interaction related to disorganized thinking for a client with schizotypal personality disorder. Based on this nursing diagnosis, which nursing intervention takes highest priority?
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Solution
Establishing a one-on-one relationship with the client
Option B: By establishing a one-on-one relationship, the nurse helps the client learn how to interact with people in new situations.
Options A, C, and D: The other options are appropriate but should take place only after the nurse-client relationship is established.
A client who’s taking antipsychotic medication develops a very high temperature, severe muscle rigidity, tachycardia, and rapid deterioration in mental status. The nurse suspects what complication of antipsychotic therapy?
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Solution
Neuroleptic malignant syndrome (NMS)
Option D: A rare but potentially fatal condition of antipsychotic medication is called NMS. It generally starts with an elevated temperature and severe extrapyramidal effects.
Option A: Agranulocytosis is a blood disorder.
Option B: Symptoms of extrapyramidal effects include tremors, restlessness, muscle spasms, and pseudoparkinsonism.
Option C: Anticholinergic effects include blurred vision, drowsiness, and dry mouth.
The definition of nihilistic delusions is:
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Solution
false ideas about the self, others, or the world
Option C: Nihilistic delusions are false ideas about the self, others, or the world.
Option A: Somatic delusions involve a false belief about the functioning of the body.
Option B: Body dysmorphic disorder is characterized by a belief that the body is deformed or defective in a specific way.
Option D: Apraxia is the inability to carry out motor activities.
During the initial interview, a client with schizophrenia suddenly turns to the empty chair beside him and whispers, “Now just leave. I told you to stay home. There isn’t enough work here for both of us!” What is the nurse’s best initial response?
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Solution
“When people are under stress, they may see things or hear things that others don’t. Is that what just happened?”
Option A: This response makes the client feel that experiencing hallucinations is acceptable and promotes an open, therapeutic relationship.
Option B: Directing the client to look at the nurse wouldn’t address the obvious issue of the hallucination.
Options C and D: Confrontational approaches are likely to elicit an uninformative or negative response.
A client is admitted with a diagnosis of schizotypal personality disorder. Which signs would this client exhibit during social situations?
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Solution
Paranoid thoughts
Option B: Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts.
Option A: Aggressive behavior is uncommon, although these clients may experience agitation with anxiety.
Option C: Their behavior is emotionally cold with a flattened affect, regardless of the situation.
Option D: These clients demonstrate a reduced capacity for close or dependent relationships.
What medication would probably be ordered for the acutely aggressive schizophrenic client?
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Solution
haloperidol (Haldol)
Option B: Haloperidol administered I.M. or I.V. is the drug of choice for acute aggressive psychotic behavior.
Option A: Chlorpromazine is also an antipsychotic drug; however, it causes more pronounced sedation than haloperidol.
Options C and D: Lithium carbonate is used in bipolar or manic disorder, and amitriptyline is used for depression.
A client is admitted to a psychiatric facility with a diagnosis of chronic schizophrenia. The history indicates that the client has been taking neuroleptic medication for many years. Assessment reveals unusual movements of the tongue, neck, and arms. Which condition should the nurse suspect?
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Solution
Tardive dyskinesia
Option A: Unusual movements of the tongue, neck, and arms suggest tardive dyskinesia, an adverse reaction to neuroleptic medication.
Option B: Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles.
Option C: Neuroleptic malignant syndrome causes rigidity, fever, hypertension, and diaphoresis.
Option D: Akathisia causes restlessness, anxiety, and jitteriness.
Important teaching for women in their childbearing years who are receiving antipsychotic medications includes which of the following?
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Solution
Continuing previous use of contraception during periods of amenorrhea
Option C: Women may experience amenorrhea, which is reversible, while taking antipsychotics. Amenorrhea doesn’t indicate cessation of ovulation; therefore, the client can still become pregnant. The client should be instructed to continue contraceptive use even when experiencing amenorrhea.
Option A: Dysmenorrhea isn’t an adverse effect of antipsychotics, and libido generally decreases because of the depressant effect.