NURS 260 EXAM 1 -2204 SCHIZOPHRENIA AND OTHER
PSYCHOTIC DISORDERS QUESTIONS AND VERIFIED ANSWERS
A paranoid client presents with bizarre behaviors, neologisms, and thought
insertion. Which nursing action should be prioritized to maintain this client's
safety?
A. Assess for medication noncompliance
B. Note escalating behaviors and intervene immediately
C. Interpret attempts at communication
D. Assess triggers for bizarre, inappropriate behaviors
ANS: B
The nurse should note escalating behaviors and intervene immediately to maintain this
client's safety. Early intervention may prevent an aggressive response and keep the
client and others safe.
A client diagnosed with schizoaffective disorder is admitted for social skills
training. Which information should be taught by the nurse?
A. The side effects of medications
B. Deep breathing techniques to decrease stress
C. How to make eye contact when communicating
D. How to be a leader
,ANS: C
The nurse should plan to teach the client how to make eye contact when
communicating. Social skills, such as making eye contact, can assist clients in
communicating needs and maintaining connectedness.
A 16-year-old-client diagnosed with paranoid schizophrenia experiences
command hallucinations to harm others. The client's parents ask a nurse, "Where
do the voices come from?" Which is the appropriate nursing reply?
A. "Your child has a chemical imbalance of the brain which leads to altered
thoughts."
B. "Your child's hallucinations are caused by medication interactions."
C. "Your child has too little serotonin in the brain causing delusions and
hallucinations."
D. "Your child's abnormal hormonal changes have precipitated auditory
hallucinations."
ANS: A
The nurse should explain that a chemical imbalance of the brain leads to altered
thought processes. Hallucinations, or false sensory perceptions, may occur in all five
senses. The client who hears voices is experiencing an auditory hallucination.
Parents ask a nurse how they should reply when their child, diagnosed with
paranoid schizophrenia, tells them that voices command him to harm others.
Which is the appropriate nursing reply?
, A. "Tell him to stop discussing the voices."
B. "Ignore what he is saying, while attempting to discover the underlying cause."
C. "Focus on the feelings generated by the hallucinations and present reality."
D. "Present objective evidence that the voices are not real."
ANS: C
The most appropriate response by the nurse is to instruct the parents to focus on the
feelings generated by the hallucinations and present reality. The parents should
maintain an attitude of acceptance to encourage communication but should not
reinforce the hallucinations by exploring details of content. It is inappropriate to present
logical arguments to persuade the client to accept the hallucinations as not real.
A nurse is assessing a client diagnosed with paranoid schizophrenia. The nurse
asks the client, "Do you receive special messages from certain sources, such as
the television or radio?" Which potential symptom of this disorder is the nurse
assessing?
A. Thought insertion
B. Paranoid delusions
C. Magical thinking
D. Delusions of reference
ANS: D
The nurse is assessing for the potential symptom of delusions of reference. A client who
believes that he or she receives messages through the radio is experiencing delusions
PSYCHOTIC DISORDERS QUESTIONS AND VERIFIED ANSWERS
A paranoid client presents with bizarre behaviors, neologisms, and thought
insertion. Which nursing action should be prioritized to maintain this client's
safety?
A. Assess for medication noncompliance
B. Note escalating behaviors and intervene immediately
C. Interpret attempts at communication
D. Assess triggers for bizarre, inappropriate behaviors
ANS: B
The nurse should note escalating behaviors and intervene immediately to maintain this
client's safety. Early intervention may prevent an aggressive response and keep the
client and others safe.
A client diagnosed with schizoaffective disorder is admitted for social skills
training. Which information should be taught by the nurse?
A. The side effects of medications
B. Deep breathing techniques to decrease stress
C. How to make eye contact when communicating
D. How to be a leader
,ANS: C
The nurse should plan to teach the client how to make eye contact when
communicating. Social skills, such as making eye contact, can assist clients in
communicating needs and maintaining connectedness.
A 16-year-old-client diagnosed with paranoid schizophrenia experiences
command hallucinations to harm others. The client's parents ask a nurse, "Where
do the voices come from?" Which is the appropriate nursing reply?
A. "Your child has a chemical imbalance of the brain which leads to altered
thoughts."
B. "Your child's hallucinations are caused by medication interactions."
C. "Your child has too little serotonin in the brain causing delusions and
hallucinations."
D. "Your child's abnormal hormonal changes have precipitated auditory
hallucinations."
ANS: A
The nurse should explain that a chemical imbalance of the brain leads to altered
thought processes. Hallucinations, or false sensory perceptions, may occur in all five
senses. The client who hears voices is experiencing an auditory hallucination.
Parents ask a nurse how they should reply when their child, diagnosed with
paranoid schizophrenia, tells them that voices command him to harm others.
Which is the appropriate nursing reply?
, A. "Tell him to stop discussing the voices."
B. "Ignore what he is saying, while attempting to discover the underlying cause."
C. "Focus on the feelings generated by the hallucinations and present reality."
D. "Present objective evidence that the voices are not real."
ANS: C
The most appropriate response by the nurse is to instruct the parents to focus on the
feelings generated by the hallucinations and present reality. The parents should
maintain an attitude of acceptance to encourage communication but should not
reinforce the hallucinations by exploring details of content. It is inappropriate to present
logical arguments to persuade the client to accept the hallucinations as not real.
A nurse is assessing a client diagnosed with paranoid schizophrenia. The nurse
asks the client, "Do you receive special messages from certain sources, such as
the television or radio?" Which potential symptom of this disorder is the nurse
assessing?
A. Thought insertion
B. Paranoid delusions
C. Magical thinking
D. Delusions of reference
ANS: D
The nurse is assessing for the potential symptom of delusions of reference. A client who
believes that he or she receives messages through the radio is experiencing delusions
