1. 1. Question
A psychotic client reports to the evening nurse that the day nurse put
something suspicious in his water with his medication. The nurse
replies, “You’re worried about your medication?” The nurse’s
communication is:
o A. An example of presenting reality
o B. Reinforcing the client’s delusions
o C. Focusing on emotional content
o D. A non-therapeutic technique called mind-reading
Incorrect
Correct Answer: C. Focusing on emotional content
The nurse should help the client focus on the emotional content rather
than delusional material. Sometimes during a conversation, patients
mention something particularly important. When this happens, nurses
can focus on their statement, prompting patients to discuss it further.
Patients don’t always have an objective perspective on what is
relevant to their case; as impartial observers, nurses can more easily
pick out the topics to focus on.
Option A: Presenting reality isn’t helpful because it can lead to
confrontation and disengagement. It’s frequently useful for
nurses to summarize what patients have said after the fact. This
demonstrates to patients that the nurse was listening and allows
the nurse to document conversations. Ending a summary with a
phrase like “Does that sound correct?” gives patients explicit
permission to make corrections if they’re necessary.
Option B: Agreeing with the client and supporting his beliefs are
reinforcing delusions. Patients often ask nurses for advice about
what they should do about particular problems or in specific
situations. Nurses can ask patients what they think they should
do, which encourages patients to be accountable for their own
actions and helps them come up with solutions themselves.
Option D: Mind reading isn’t therapeutic. Similar to active
listening, asking patients for clarification when they say
something confusing or ambiguous is important. Saying
something like “I’m not sure I understand. Can you explain it to
, me?” helps nurses ensure they understand what’s actually being
said and can help patients process their ideas more thoroughly
2. 2. Question
A client is admitted to the inpatient unit of the mental health center
with a diagnosis of paranoid schizophrenia. He’s shouting that the
government of France is trying to assassinate him. Which of the
following responses is most appropriate?
A. “I think you’re wrong. France is a friendly country and an ally of
the United States. Their government wouldn’t try to kill you.”
B. “I find it hard to believe that a foreign government or
anyone else is trying to hurt you. You must feel frightened by
this.”
C. “You’re wrong. Nobody is trying to kill you.”
D. “A foreign government is trying to kill you? Please tell me more
about it.”
Incorrect
Correct Answer: B. “I find it hard to believe that a foreign
government or anyone else is trying to hurt you. You must feel
frightened by this.”
Responses should focus on reality while acknowledging the client’s
feelings. Sometimes during a conversation, patients mention
something particularly important. When this happens, nurses can focus
on their statement, prompting patients to discuss it further. Patients
don’t always have an objective perspective on what is relevant to their
case; as impartial observers, nurses can more easily pick out the topics
to focus on.
Option A: Arguing with the client or denying his belief isn’t
therapeutic. By using nonverbal and verbal cues such as nodding
and saying “I see,” nurses can encourage patients to continue
talking. Active listening involves showing interest in what patients
have to say, acknowledging that you’re listening and
understanding, and engaging with them throughout the
conversation. Nurses can offer general leads such as “What
happened next?” to guide the conversation or propel it forward.
, Option C: Arguing can also inhibit development of a trusting
relationship. Continuing to talk about delusions may aggravate
the psychosis. It’s frequently useful for nurses to summarize what
patients have said after the fact. This demonstrates to patients
that the nurse was listening and allows the nurse to document
conversations. Ending a summary with a phrase like “Does that
sound correct?” gives patients explicit permission to make
corrections if they’re necessary.
Option D: Asking the client if a foreign government is trying to
kill him may increase his anxiety level and can reinforce his
delusions. Voicing doubt can be a gentler way to call attention to
the incorrect or delusional
3. 3. Question
A client receiving haloperidol (Haldol) complains of a stiff jaw and
difficulty swallowing. The nurse’s first action is to:
A. Reassure the client and administer as needed lorazepam
(Ativan) I.M.
B. Administer as needed dose of benztropine (Cogentin)
I.M. as ordered.
C. Administer as needed dose of benztropine (Cogentin) by mouth
as ordered.
D. Administer as needed dose of haloperidol (Haldol) by mouth.
Incorrect
Correct Answer: B. Administer as needed dose of benztropine
(Cogentin) I.M. as ordered.
The client is most likely suffering from muscle rigidity due to
haloperidol. I.M. benztropine should be administered to prevent
asphyxia or aspiration. The extrapyramidal symptoms are muscular
weakness or rigidity, a generalized or localized tremor that may be
characterized by the akinetic or agitation types of movements,
respectively. Haloperidol overdose is also associated with ECG changes
known as torsade de pointes, which may cause arrhythmia or cardiac
arrest.
Option A: Lorazepam treats anxiety, not extrapyramidal effects.
Lorazepam is a benzodiazepine medication developed by DJ
, Richards. It went on the market in the United States in 1977.
Lorazepam has common use as the sedative and anxiolytic of
choice in the inpatient setting owing to its fast (1 to 3 minute)
onset of action when administered intravenously. Lorazepam is
also one of the few sedative-hypnotics with a relatively clean side
effect profile. Lorazepam is FDA approved for short-term (4
months) relief of anxiety symptoms related to anxiety disorders,
anxiety-associated insomnia, anesthesia premedication in adults
to relieve anxiety, or to produce sedation/amnesia, and treatment
of status epilepticus.
Option C: Benztropine belongs to the synthetic class of
muscarinic receptor antagonists (anticholinergic drugs). Thus, it
has a structure similar to that of diphenhydramine and atropine.
However, it is long-acting so that its administration can be with
less frequency than diphenhydramine. It also induces less CNS
stimulation effect compared to that of trihexyphenidyl, making it
a preferable drug of choice for geriatric patients.
Option D: Another dose of haloperidol would increase the
severity of the reaction. Since there is no specific antidote,
supportive treatment is the mainstay of haloperidol toxicity. If a
patient develops signs and symptoms of toxicities, the clinician
should consider gastric lavage or induction of emesis as soon as
possible, followed by the administration of activated charcoal.
Maintenance of Airway, Breathing, and circulation are the most
important factors for survival.
4. 4. Question
The nurse is caring for a client with schizophrenia who experiences
auditory hallucinations. The client appears to be listening to someone
who isn’t visible. He gestures, shouts angrily, and stops shouting in
mid-sentence. Which nursing intervention is the most appropriate?
A. Approach the client and touch him to get his attention.
B. Encourage the client to go to his room where he’ll experience
fewer distractions.
C. Acknowledge that the client is hearing voices but make it
clear that the nurse doesn’t hear these voices.
D. Ask the client to describe what the voices are saying.
A psychotic client reports to the evening nurse that the day nurse put
something suspicious in his water with his medication. The nurse
replies, “You’re worried about your medication?” The nurse’s
communication is:
o A. An example of presenting reality
o B. Reinforcing the client’s delusions
o C. Focusing on emotional content
o D. A non-therapeutic technique called mind-reading
Incorrect
Correct Answer: C. Focusing on emotional content
The nurse should help the client focus on the emotional content rather
than delusional material. Sometimes during a conversation, patients
mention something particularly important. When this happens, nurses
can focus on their statement, prompting patients to discuss it further.
Patients don’t always have an objective perspective on what is
relevant to their case; as impartial observers, nurses can more easily
pick out the topics to focus on.
Option A: Presenting reality isn’t helpful because it can lead to
confrontation and disengagement. It’s frequently useful for
nurses to summarize what patients have said after the fact. This
demonstrates to patients that the nurse was listening and allows
the nurse to document conversations. Ending a summary with a
phrase like “Does that sound correct?” gives patients explicit
permission to make corrections if they’re necessary.
Option B: Agreeing with the client and supporting his beliefs are
reinforcing delusions. Patients often ask nurses for advice about
what they should do about particular problems or in specific
situations. Nurses can ask patients what they think they should
do, which encourages patients to be accountable for their own
actions and helps them come up with solutions themselves.
Option D: Mind reading isn’t therapeutic. Similar to active
listening, asking patients for clarification when they say
something confusing or ambiguous is important. Saying
something like “I’m not sure I understand. Can you explain it to
, me?” helps nurses ensure they understand what’s actually being
said and can help patients process their ideas more thoroughly
2. 2. Question
A client is admitted to the inpatient unit of the mental health center
with a diagnosis of paranoid schizophrenia. He’s shouting that the
government of France is trying to assassinate him. Which of the
following responses is most appropriate?
A. “I think you’re wrong. France is a friendly country and an ally of
the United States. Their government wouldn’t try to kill you.”
B. “I find it hard to believe that a foreign government or
anyone else is trying to hurt you. You must feel frightened by
this.”
C. “You’re wrong. Nobody is trying to kill you.”
D. “A foreign government is trying to kill you? Please tell me more
about it.”
Incorrect
Correct Answer: B. “I find it hard to believe that a foreign
government or anyone else is trying to hurt you. You must feel
frightened by this.”
Responses should focus on reality while acknowledging the client’s
feelings. Sometimes during a conversation, patients mention
something particularly important. When this happens, nurses can focus
on their statement, prompting patients to discuss it further. Patients
don’t always have an objective perspective on what is relevant to their
case; as impartial observers, nurses can more easily pick out the topics
to focus on.
Option A: Arguing with the client or denying his belief isn’t
therapeutic. By using nonverbal and verbal cues such as nodding
and saying “I see,” nurses can encourage patients to continue
talking. Active listening involves showing interest in what patients
have to say, acknowledging that you’re listening and
understanding, and engaging with them throughout the
conversation. Nurses can offer general leads such as “What
happened next?” to guide the conversation or propel it forward.
, Option C: Arguing can also inhibit development of a trusting
relationship. Continuing to talk about delusions may aggravate
the psychosis. It’s frequently useful for nurses to summarize what
patients have said after the fact. This demonstrates to patients
that the nurse was listening and allows the nurse to document
conversations. Ending a summary with a phrase like “Does that
sound correct?” gives patients explicit permission to make
corrections if they’re necessary.
Option D: Asking the client if a foreign government is trying to
kill him may increase his anxiety level and can reinforce his
delusions. Voicing doubt can be a gentler way to call attention to
the incorrect or delusional
3. 3. Question
A client receiving haloperidol (Haldol) complains of a stiff jaw and
difficulty swallowing. The nurse’s first action is to:
A. Reassure the client and administer as needed lorazepam
(Ativan) I.M.
B. Administer as needed dose of benztropine (Cogentin)
I.M. as ordered.
C. Administer as needed dose of benztropine (Cogentin) by mouth
as ordered.
D. Administer as needed dose of haloperidol (Haldol) by mouth.
Incorrect
Correct Answer: B. Administer as needed dose of benztropine
(Cogentin) I.M. as ordered.
The client is most likely suffering from muscle rigidity due to
haloperidol. I.M. benztropine should be administered to prevent
asphyxia or aspiration. The extrapyramidal symptoms are muscular
weakness or rigidity, a generalized or localized tremor that may be
characterized by the akinetic or agitation types of movements,
respectively. Haloperidol overdose is also associated with ECG changes
known as torsade de pointes, which may cause arrhythmia or cardiac
arrest.
Option A: Lorazepam treats anxiety, not extrapyramidal effects.
Lorazepam is a benzodiazepine medication developed by DJ
, Richards. It went on the market in the United States in 1977.
Lorazepam has common use as the sedative and anxiolytic of
choice in the inpatient setting owing to its fast (1 to 3 minute)
onset of action when administered intravenously. Lorazepam is
also one of the few sedative-hypnotics with a relatively clean side
effect profile. Lorazepam is FDA approved for short-term (4
months) relief of anxiety symptoms related to anxiety disorders,
anxiety-associated insomnia, anesthesia premedication in adults
to relieve anxiety, or to produce sedation/amnesia, and treatment
of status epilepticus.
Option C: Benztropine belongs to the synthetic class of
muscarinic receptor antagonists (anticholinergic drugs). Thus, it
has a structure similar to that of diphenhydramine and atropine.
However, it is long-acting so that its administration can be with
less frequency than diphenhydramine. It also induces less CNS
stimulation effect compared to that of trihexyphenidyl, making it
a preferable drug of choice for geriatric patients.
Option D: Another dose of haloperidol would increase the
severity of the reaction. Since there is no specific antidote,
supportive treatment is the mainstay of haloperidol toxicity. If a
patient develops signs and symptoms of toxicities, the clinician
should consider gastric lavage or induction of emesis as soon as
possible, followed by the administration of activated charcoal.
Maintenance of Airway, Breathing, and circulation are the most
important factors for survival.
4. 4. Question
The nurse is caring for a client with schizophrenia who experiences
auditory hallucinations. The client appears to be listening to someone
who isn’t visible. He gestures, shouts angrily, and stops shouting in
mid-sentence. Which nursing intervention is the most appropriate?
A. Approach the client and touch him to get his attention.
B. Encourage the client to go to his room where he’ll experience
fewer distractions.
C. Acknowledge that the client is hearing voices but make it
clear that the nurse doesn’t hear these voices.
D. Ask the client to describe what the voices are saying.
