Test bank For Varcarolis Foundations of Psychiatric-Mental
Health Nursing 9th Edition 9780323697071 | All Chapters with
Answers and Rationals
.
A client has had difficulty keeping a job because of arguing with co-workers and accusing them of
conspiracy. Today this client shouts, "They're all plotting to destroy me. Isn't that true?" what is the
nurse's most therapeutic response?
a. "Everyone here is trying to help you. No one wants to harm you."
b. "Feeling that people want to destroy you must be very frightening."
c. "That is not true. People here are trying to help you if you will let them."
d. "Staff members are health care professionals who are qualified to help you." - ANSWER: ANS: B
Resist focusing on content; instead, focus on the feelings the client is expressing. This strategy
prevents arguing about the reality of delusional beliefs. Such arguments increase client anxiety and
the tenacity with which the client holds to the delusion. The other options focus on content and
provide opportunity for argument.
A newly admitted client diagnosed with schizophrenia is hypervigilant and constantly scans the
environment. The client states, "I saw two doctors talking in the hall. They were plotting to kill me."
The nurse may correctly assess this behavior using which term?
a. echolalia.
b. paranoia
c. a delusion of infidelity.
d. an auditory hallucination. - ANSWER: ANS: B
Paranoia is an irrational fear, ranging from mild (being suspicious, wary, guarded) to profound
(believing irrationally that another person intends to kill you).; for example, when seeing two people
talking, the individual assumes they are talking about him or her. The other terms do not correspond
with the scenario.
A client diagnosed with schizophrenia says, "My co-workers are out to get me. I also saw two
doctors plotting to kill me." How does this client perceive the environment? a. Disorganized
b. Dangerous
c. Supportive
d. Bizarre - ANSWER: ANS: B
Test bank Varcarolis' Foundations of Psychiatric-Mental Health Nursing 9th Edition 124
The client sees the world as hostile and dangerous. This assessment is important because the nurse
can be more effective by using empathy to respond to the client. Data are not present to support any
of the other options.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Assessment MSC:
4. When a client diagnosed with schizophrenia was discharged 6 months ago, haloperidol was
prescribed. The client now says, "I stopped taking those pills. They made me feel like a robot." What
are common side effects the nurse should validate with the client?
a. Sedation and muscle stiffness
b. Sweating, nausea, and diarrhea
c. Mild fever, sore throat, and skin rash
d. Headache, watery eyes, and runny nose - ANSWER: ANS: A
Typical antipsychotic drugs often produce sedation and extrapyramidal side effects such as stiffness
and gait disturbance, effects the client might describe as making him or her feel like a "robot." The
side effects mentioned in the other options are usually not associated with typical antipsychotic
therapy or would not have the effect described by the client.
5. Which hallucination expressed by a client necessitates the nurse to implement safety measures?
a. "I hear angels playing harps."
,b. "The voices say everyone is trying to kill me."
c. "My dead father tells me I am a good person."
d. "The voices talk only at night when I'm trying to sleep." - ANSWER: ANS: B
The correct response indicates the client is experiencing paranoia. Paranoia often leads to fearfulness,
and the client may attempt to strike out at others to protect self. The distracters are comforting
hallucinations or do not indicate paranoia.
6. A client's care plan includes monitoring for auditory hallucinations. Which assessment findings
suggest the client may be hallucinating?
a. Detachment and overconfidence
b. Darting eyes, tilted head, mumbling to self
c. Euphoric mood, hyperactivity, distractibility
d. Foot tapping and repeatedly writing the same phrase - ANSWER: ANS: B
Clues to hallucinations include eyes looking around the room as though to find the speaker, tilting the
head to one side as though listening intently, and grimacing, mumbling, or talking aloud as though
responding conversationally to someone.
PTS: 1 DIF: Cognitive Level: Understand (Com
7.
A health care provider considers which antipsychotic medication to prescribe for a client diagnosed
with schizophrenia who has auditory hallucinations and poor social function. The client is also
overweight and hypertensive. Which drug should the nurse advocate?
a. Clozapine
b. Ziprasidone
c. Olanzapine
d. Aripiprazole - ANSWER: ANS: D
Aripiprazole is a third-generation atypical antipsychotic effective against both positive and negative
symptoms of schizophrenia. It causes little or no weight gain and no increase in glucose, high- or low-
density lipoprotein cholesterol, or triglycerides, making it a reasonable choice for a client with obesity
or heart disease. Clozapine may produce agranulocytosis, making it a poor choice as a first-line agent.
Ziprasidone may prolong the QT interval, making it a poor choice for a client with cardiac disease.
Olanzapine fosters weight gain.
A client diagnosed with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It
blows away. Get it?" What is the nurse's most therapeutic response?
a. "Nothing you are saying is clear."
b. "Your thoughts are very disconnected."
c. "Try to organize your thoughts and then tell me again."
d. "I am having difficulty understanding what you are saying." - ANSWER: ANS: D
When a client's speech is loosely associated, confused, and disorganized, pretending to understand is
useless. The nurse should tell the client that he or she is having difficulty understanding what the
client is saying. If a theme is discernible, ask the client to talk about the theme. The incorrect options
tend to place blame for the poor communication with the client. The correct response places the
difficulty with the nurse rather than being accusatory.
A client diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates
catatonia. Which client needs are of priority importance?
a. Self-esteem
b. Psychosocial
c. Physiological
d. Self-actualization - ANSWER: ANS: C
Physiological needs must be met to preserve life. A client with catatonia must be fed by hand or tube,
toileted, given range-of-motion exercises, and so forth to preserve physiological integrity. Cattonia
may also precipitate a risk for falls; therefore, safety is a concern. Higher level needs are of lesser
concern.
PTS: 1 DIF: Cognitiv
, 10.
A client diagnosed with schizophrenia demonstrates little spontaneous movement and has catatonia.
The client's activities of daily living are severely compromised. What will be an appropriate outcome
for this client?
a. demonstrates increased interest in the environment by the end of week 1.
b. performs self-care activities with coaching by the end of day 3.
c. gradually takes the initiative for self-care by the end of week 2.
d. accepts tube feeding without objection by day 2. - ANSWER: ANS: B
Outcomes related to self-care deficit nursing diagnoses should deal with increasing ability to perform
self-care tasks independently, such as feeding, bathing, dressing, and toileting. Performing the tasks
with coaching by nursing staff denotes improvement over the complete inability to perform the tasks.
The incorrect options are not directly related to self-care activities, difficult to measure, and unrelated
to maintenance of nutrition.
A nurse observes a catatonic client standing immobile, facing the wall with one arm extended in a
salute. The client remains immobile in this position for 15 minutes, moving only when the nurse
gently lowers the arm. What is the name of this phenomenon?
a. Echolalia
b. Catatonia
c. Depersonalization
d. Thought withdrawal - ANSWER: ANS: B
Catatonia is the ability to hold distorted postures for extended periods of time, as though the client
were molded in wax. Echolalia is a speech pattern. Depersonalization refers to a feeling state. Thought
withdrawal refers to an alteration in thinking.
A nurse leads a psychoeducational group about first-generation antipsychotic medications with six
adult men diagnosed with schizophrenia. The nurse will monitor for concerns regarding body image
with respect to which potential side effect of these medications?
a. Constipation
b. Gynecomastia
c. Visual changes
d. Photosensitivity - ANSWER: ANS: B
FGAs (first-generation antipsychotic) stimulate release of prolactin, which can result in gynecomastia
(enlargement of the breasts) as well as other changes in sexual function. Men may experience
disturbances in body image as a result of gynecomastia. Other side effects of FGAs may be disturbing
to other aspects of the client's physical health but are not likely to bother body image.
13. A nurse leads a psychoeducational group about problem solving with six adults diagnosed with
schizophrenia. Which teaching strategy is likely to be most effective?
a. Suggest analogies that might apply to a common daily problem.
b. Assign each participant a problem to solve independently and present to the group.
c. Ask each client to read aloud a short segment from a book about problem solving.
d. Invite participants to come up with solution to getting incorrect change for a
purchase. - ANSWER: ANS: D
Concrete thinking, an impaired ability to think abstractly resulting in interpreting or perceiving things
in a literal manner, is evident in many clients diagnosed with schizophrenia. People who think
concretely benefit from concrete situations during education. Finding a solution in order to get
incorrect change for a purchase is an example of a concrete situation. Analogies require abstract
thinking and insight. Independently solving a problem and presenting it to the group may be
intimidating. All participants may or may not be literate.
14. A nurse educates a client about the antipsychotic medication regime. Afterward, which comment
by the client indicates the teaching was effective?
a. "I will need higher and higher doses of my medication as time goes on."
b. "I need to store my medication in a cool dark place, such as the refrigerator."
c. "Taking this medication regularly will reduce the severity of my symptoms."
d. "If I run out or stop taking my medication, I will experience withdrawal
Health Nursing 9th Edition 9780323697071 | All Chapters with
Answers and Rationals
.
A client has had difficulty keeping a job because of arguing with co-workers and accusing them of
conspiracy. Today this client shouts, "They're all plotting to destroy me. Isn't that true?" what is the
nurse's most therapeutic response?
a. "Everyone here is trying to help you. No one wants to harm you."
b. "Feeling that people want to destroy you must be very frightening."
c. "That is not true. People here are trying to help you if you will let them."
d. "Staff members are health care professionals who are qualified to help you." - ANSWER: ANS: B
Resist focusing on content; instead, focus on the feelings the client is expressing. This strategy
prevents arguing about the reality of delusional beliefs. Such arguments increase client anxiety and
the tenacity with which the client holds to the delusion. The other options focus on content and
provide opportunity for argument.
A newly admitted client diagnosed with schizophrenia is hypervigilant and constantly scans the
environment. The client states, "I saw two doctors talking in the hall. They were plotting to kill me."
The nurse may correctly assess this behavior using which term?
a. echolalia.
b. paranoia
c. a delusion of infidelity.
d. an auditory hallucination. - ANSWER: ANS: B
Paranoia is an irrational fear, ranging from mild (being suspicious, wary, guarded) to profound
(believing irrationally that another person intends to kill you).; for example, when seeing two people
talking, the individual assumes they are talking about him or her. The other terms do not correspond
with the scenario.
A client diagnosed with schizophrenia says, "My co-workers are out to get me. I also saw two
doctors plotting to kill me." How does this client perceive the environment? a. Disorganized
b. Dangerous
c. Supportive
d. Bizarre - ANSWER: ANS: B
Test bank Varcarolis' Foundations of Psychiatric-Mental Health Nursing 9th Edition 124
The client sees the world as hostile and dangerous. This assessment is important because the nurse
can be more effective by using empathy to respond to the client. Data are not present to support any
of the other options.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Assessment MSC:
4. When a client diagnosed with schizophrenia was discharged 6 months ago, haloperidol was
prescribed. The client now says, "I stopped taking those pills. They made me feel like a robot." What
are common side effects the nurse should validate with the client?
a. Sedation and muscle stiffness
b. Sweating, nausea, and diarrhea
c. Mild fever, sore throat, and skin rash
d. Headache, watery eyes, and runny nose - ANSWER: ANS: A
Typical antipsychotic drugs often produce sedation and extrapyramidal side effects such as stiffness
and gait disturbance, effects the client might describe as making him or her feel like a "robot." The
side effects mentioned in the other options are usually not associated with typical antipsychotic
therapy or would not have the effect described by the client.
5. Which hallucination expressed by a client necessitates the nurse to implement safety measures?
a. "I hear angels playing harps."
,b. "The voices say everyone is trying to kill me."
c. "My dead father tells me I am a good person."
d. "The voices talk only at night when I'm trying to sleep." - ANSWER: ANS: B
The correct response indicates the client is experiencing paranoia. Paranoia often leads to fearfulness,
and the client may attempt to strike out at others to protect self. The distracters are comforting
hallucinations or do not indicate paranoia.
6. A client's care plan includes monitoring for auditory hallucinations. Which assessment findings
suggest the client may be hallucinating?
a. Detachment and overconfidence
b. Darting eyes, tilted head, mumbling to self
c. Euphoric mood, hyperactivity, distractibility
d. Foot tapping and repeatedly writing the same phrase - ANSWER: ANS: B
Clues to hallucinations include eyes looking around the room as though to find the speaker, tilting the
head to one side as though listening intently, and grimacing, mumbling, or talking aloud as though
responding conversationally to someone.
PTS: 1 DIF: Cognitive Level: Understand (Com
7.
A health care provider considers which antipsychotic medication to prescribe for a client diagnosed
with schizophrenia who has auditory hallucinations and poor social function. The client is also
overweight and hypertensive. Which drug should the nurse advocate?
a. Clozapine
b. Ziprasidone
c. Olanzapine
d. Aripiprazole - ANSWER: ANS: D
Aripiprazole is a third-generation atypical antipsychotic effective against both positive and negative
symptoms of schizophrenia. It causes little or no weight gain and no increase in glucose, high- or low-
density lipoprotein cholesterol, or triglycerides, making it a reasonable choice for a client with obesity
or heart disease. Clozapine may produce agranulocytosis, making it a poor choice as a first-line agent.
Ziprasidone may prolong the QT interval, making it a poor choice for a client with cardiac disease.
Olanzapine fosters weight gain.
A client diagnosed with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It
blows away. Get it?" What is the nurse's most therapeutic response?
a. "Nothing you are saying is clear."
b. "Your thoughts are very disconnected."
c. "Try to organize your thoughts and then tell me again."
d. "I am having difficulty understanding what you are saying." - ANSWER: ANS: D
When a client's speech is loosely associated, confused, and disorganized, pretending to understand is
useless. The nurse should tell the client that he or she is having difficulty understanding what the
client is saying. If a theme is discernible, ask the client to talk about the theme. The incorrect options
tend to place blame for the poor communication with the client. The correct response places the
difficulty with the nurse rather than being accusatory.
A client diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates
catatonia. Which client needs are of priority importance?
a. Self-esteem
b. Psychosocial
c. Physiological
d. Self-actualization - ANSWER: ANS: C
Physiological needs must be met to preserve life. A client with catatonia must be fed by hand or tube,
toileted, given range-of-motion exercises, and so forth to preserve physiological integrity. Cattonia
may also precipitate a risk for falls; therefore, safety is a concern. Higher level needs are of lesser
concern.
PTS: 1 DIF: Cognitiv
, 10.
A client diagnosed with schizophrenia demonstrates little spontaneous movement and has catatonia.
The client's activities of daily living are severely compromised. What will be an appropriate outcome
for this client?
a. demonstrates increased interest in the environment by the end of week 1.
b. performs self-care activities with coaching by the end of day 3.
c. gradually takes the initiative for self-care by the end of week 2.
d. accepts tube feeding without objection by day 2. - ANSWER: ANS: B
Outcomes related to self-care deficit nursing diagnoses should deal with increasing ability to perform
self-care tasks independently, such as feeding, bathing, dressing, and toileting. Performing the tasks
with coaching by nursing staff denotes improvement over the complete inability to perform the tasks.
The incorrect options are not directly related to self-care activities, difficult to measure, and unrelated
to maintenance of nutrition.
A nurse observes a catatonic client standing immobile, facing the wall with one arm extended in a
salute. The client remains immobile in this position for 15 minutes, moving only when the nurse
gently lowers the arm. What is the name of this phenomenon?
a. Echolalia
b. Catatonia
c. Depersonalization
d. Thought withdrawal - ANSWER: ANS: B
Catatonia is the ability to hold distorted postures for extended periods of time, as though the client
were molded in wax. Echolalia is a speech pattern. Depersonalization refers to a feeling state. Thought
withdrawal refers to an alteration in thinking.
A nurse leads a psychoeducational group about first-generation antipsychotic medications with six
adult men diagnosed with schizophrenia. The nurse will monitor for concerns regarding body image
with respect to which potential side effect of these medications?
a. Constipation
b. Gynecomastia
c. Visual changes
d. Photosensitivity - ANSWER: ANS: B
FGAs (first-generation antipsychotic) stimulate release of prolactin, which can result in gynecomastia
(enlargement of the breasts) as well as other changes in sexual function. Men may experience
disturbances in body image as a result of gynecomastia. Other side effects of FGAs may be disturbing
to other aspects of the client's physical health but are not likely to bother body image.
13. A nurse leads a psychoeducational group about problem solving with six adults diagnosed with
schizophrenia. Which teaching strategy is likely to be most effective?
a. Suggest analogies that might apply to a common daily problem.
b. Assign each participant a problem to solve independently and present to the group.
c. Ask each client to read aloud a short segment from a book about problem solving.
d. Invite participants to come up with solution to getting incorrect change for a
purchase. - ANSWER: ANS: D
Concrete thinking, an impaired ability to think abstractly resulting in interpreting or perceiving things
in a literal manner, is evident in many clients diagnosed with schizophrenia. People who think
concretely benefit from concrete situations during education. Finding a solution in order to get
incorrect change for a purchase is an example of a concrete situation. Analogies require abstract
thinking and insight. Independently solving a problem and presenting it to the group may be
intimidating. All participants may or may not be literate.
14. A nurse educates a client about the antipsychotic medication regime. Afterward, which comment
by the client indicates the teaching was effective?
a. "I will need higher and higher doses of my medication as time goes on."
b. "I need to store my medication in a cool dark place, such as the refrigerator."
c. "Taking this medication regularly will reduce the severity of my symptoms."
d. "If I run out or stop taking my medication, I will experience withdrawal
