Psychotic Disorders-NCLEX 3000 (Answered
With Rationale)
"A client is prescribed quetiapine (Seroquel), 400 mg by mouth daily in two
divided doses, to treat psychosis. The pharmacy dispenses 200 mg tablets. How
many tablets should the nurse administer with each dose?
1
"The nurse is providing care to a client with a catatonic type of schizophrenia
who exhibits extreme negativism. To help the client meet his basic needs, the
nurse should:
"tell the client specifically and concisely what needs to be done.
"A client is about to be discharged with a prescription for the antipsychotic agent
haloperidol (Haldol), 10 mg by mouth twice per day. During a discharge teaching
session, the nurse should provide which instruction to the client?
"Apply a sunscreen before exposure to the sun.
"Hormonal effects of the antipsychotic medications include:
"retrograde ejaculation and gynecomastia.
""During data collection, a client with schizophrenia leaves his arm in the air after
the nurse has taken his blood pressure. His action shows evidence of:
waxy flexibility.
"Every day for the past 2 weeks, a client with schizophrenia stands up during
group therapy and screams, ""Get out of here right now! The elevator bombs are
going to explode in 3 minutes!"" The next time this happens, how should the
nurse respond?
"I know you think there are bombs in the elevator, but there aren't."
"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:
"focusing on emotional content.
(SELECT ALL THAT APPLY) The nurse is monitoring a client who appears to be
hallucinating. She notes paranoid content in the client's speech and he appears
agitated. The client is gesturing at a figure on the television. Which of the
following nursing interventions are appropriate?
"(2) Reinforce that the client isn't in any danger. (3) Acknowledge the presence of the
hallucinations. (6) Use a calm voice and simple commands.
"Yesterday, a client with schizophrenia began treatment with haloperidol (Haldol).
Today, the nurse notices that the client is holding his head to one side and
complaining of neck and jaw spasms. What should the nurse do?
"Evaluate the client for adverse reactions to haloperidol.
"A 54-year-old client who was admitted to the psychiatric unit during an acute
phase of paranoid schizophrenia has hardly eaten and hasn't bathed or changed
his clothes for 3 weeks. He undergoes 4 weeks of psychotherapy and medication
adjustment. Which statement by the client indicates that he's ready for
discharge?
, "I know a sign of my disease is not bathing and maintaining my personal appearance."
"A 39-year-old client in the residual phase of paranoid schizophrenia asks to see
his medical records. Which action by the nurse is most appropriate?
"Notify the nursing supervisor, sign a records release form, and then give the client a
copy of his records.
During a group therapy session in the psychiatric unit, a client constantly
interrupts with impulsive behavior and exaggerated stories that cast her as a hero
or princess. She also manipulates the group with attention-seeking behaviors,
such as sexual comments and angry outbursts. The nurse realizes that these
behaviors are typical of:
"histrionic personality disorder.
"A schizophrenic client with delusions tells the nurse, ""There is a man wearing a
red coat who's out to get me."" The client exhibits increasing anxiety when
focusing on the delusions. Which of the following would be an appropriate
response?
"This subject seems to be troubling you. Let's walk to the activity room."
"Important teaching for a client receiving risperidone (Risperdal) would include
advising the client to:
"notify the physician if the client notices an increase in bruising.
"A 36-year-old client with a history of schizophrenia is admitted to the emergency
department with a fever of 102° F (38.9° C), severe headache, photophobia, nuchal
rigidity, and nausea. A physician believes that a lumbar puncture is necessary to
help confirm his suspicions of meningitis. The nurse is asked to witness the
informed consent. How can the nurse best assess the client's mental status
before witnessing the consent?
"Perform a brief mental status examination to determine whether the client is oriented to
person, place, time, and purpose.
"A 50-year-old male client is hospitalized in a psychiatric unit for treatment of an
acute phase of paranoid schizophrenia with delusions of persecution. At the end
of her shift, a licensed practical nurse reports the client's status to a registered
nurse. Which observation by the licensed practical nurse indicates that the
client's condition is improving?
"After shaving and showering, the client reports that the voices have been quiet for
several days.
"(SELECT ALL THAT APPLY) A client with schizophrenia is taking the atypical
antipsychotic medication clozapine (Clozaril). Which of the following signs and
symptoms indicate the presence of adverse effects associated with this
medication?
"(1) Sore throat (4) Fever"
"The etiology of schizophrenia is best described by:
"a combination of biological, psychological, and environmental factors.
"A client receiving haloperidol (Haldol) complains of a stiff jaw and difficulty
swallowing. The nurse's first action is to:
"administer an as-needed dose of benztropine (Cogentin) I.M. as ordered.
"A client with catatonic schizophrenia is mute, can't perform activities of daily
living, and stares out the window for hours. What is the nurse's first priority?
With Rationale)
"A client is prescribed quetiapine (Seroquel), 400 mg by mouth daily in two
divided doses, to treat psychosis. The pharmacy dispenses 200 mg tablets. How
many tablets should the nurse administer with each dose?
1
"The nurse is providing care to a client with a catatonic type of schizophrenia
who exhibits extreme negativism. To help the client meet his basic needs, the
nurse should:
"tell the client specifically and concisely what needs to be done.
"A client is about to be discharged with a prescription for the antipsychotic agent
haloperidol (Haldol), 10 mg by mouth twice per day. During a discharge teaching
session, the nurse should provide which instruction to the client?
"Apply a sunscreen before exposure to the sun.
"Hormonal effects of the antipsychotic medications include:
"retrograde ejaculation and gynecomastia.
""During data collection, a client with schizophrenia leaves his arm in the air after
the nurse has taken his blood pressure. His action shows evidence of:
waxy flexibility.
"Every day for the past 2 weeks, a client with schizophrenia stands up during
group therapy and screams, ""Get out of here right now! The elevator bombs are
going to explode in 3 minutes!"" The next time this happens, how should the
nurse respond?
"I know you think there are bombs in the elevator, but there aren't."
"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:
"focusing on emotional content.
(SELECT ALL THAT APPLY) The nurse is monitoring a client who appears to be
hallucinating. She notes paranoid content in the client's speech and he appears
agitated. The client is gesturing at a figure on the television. Which of the
following nursing interventions are appropriate?
"(2) Reinforce that the client isn't in any danger. (3) Acknowledge the presence of the
hallucinations. (6) Use a calm voice and simple commands.
"Yesterday, a client with schizophrenia began treatment with haloperidol (Haldol).
Today, the nurse notices that the client is holding his head to one side and
complaining of neck and jaw spasms. What should the nurse do?
"Evaluate the client for adverse reactions to haloperidol.
"A 54-year-old client who was admitted to the psychiatric unit during an acute
phase of paranoid schizophrenia has hardly eaten and hasn't bathed or changed
his clothes for 3 weeks. He undergoes 4 weeks of psychotherapy and medication
adjustment. Which statement by the client indicates that he's ready for
discharge?
, "I know a sign of my disease is not bathing and maintaining my personal appearance."
"A 39-year-old client in the residual phase of paranoid schizophrenia asks to see
his medical records. Which action by the nurse is most appropriate?
"Notify the nursing supervisor, sign a records release form, and then give the client a
copy of his records.
During a group therapy session in the psychiatric unit, a client constantly
interrupts with impulsive behavior and exaggerated stories that cast her as a hero
or princess. She also manipulates the group with attention-seeking behaviors,
such as sexual comments and angry outbursts. The nurse realizes that these
behaviors are typical of:
"histrionic personality disorder.
"A schizophrenic client with delusions tells the nurse, ""There is a man wearing a
red coat who's out to get me."" The client exhibits increasing anxiety when
focusing on the delusions. Which of the following would be an appropriate
response?
"This subject seems to be troubling you. Let's walk to the activity room."
"Important teaching for a client receiving risperidone (Risperdal) would include
advising the client to:
"notify the physician if the client notices an increase in bruising.
"A 36-year-old client with a history of schizophrenia is admitted to the emergency
department with a fever of 102° F (38.9° C), severe headache, photophobia, nuchal
rigidity, and nausea. A physician believes that a lumbar puncture is necessary to
help confirm his suspicions of meningitis. The nurse is asked to witness the
informed consent. How can the nurse best assess the client's mental status
before witnessing the consent?
"Perform a brief mental status examination to determine whether the client is oriented to
person, place, time, and purpose.
"A 50-year-old male client is hospitalized in a psychiatric unit for treatment of an
acute phase of paranoid schizophrenia with delusions of persecution. At the end
of her shift, a licensed practical nurse reports the client's status to a registered
nurse. Which observation by the licensed practical nurse indicates that the
client's condition is improving?
"After shaving and showering, the client reports that the voices have been quiet for
several days.
"(SELECT ALL THAT APPLY) A client with schizophrenia is taking the atypical
antipsychotic medication clozapine (Clozaril). Which of the following signs and
symptoms indicate the presence of adverse effects associated with this
medication?
"(1) Sore throat (4) Fever"
"The etiology of schizophrenia is best described by:
"a combination of biological, psychological, and environmental factors.
"A client receiving haloperidol (Haldol) complains of a stiff jaw and difficulty
swallowing. The nurse's first action is to:
"administer an as-needed dose of benztropine (Cogentin) I.M. as ordered.
"A client with catatonic schizophrenia is mute, can't perform activities of daily
living, and stares out the window for hours. What is the nurse's first priority?
