Complete Solutions
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? Correct Answer "Your child
has a chemical imbalance of the brain which leads to altered
thoughts."
A client diagnosed with schizophrenia tells a nurse, "The
'Shopatouliens' took my shoes out of my room last night."
Which is an appropriate charting entry to describe this client's
statement? Correct Answer The client is expressing a
neologism
A client taking the monoamine oxidase inhibitor (MAOI)
phenelzine (Nardil) is instructed by the nurse to avoid which
foods and beverages? Correct Answer Aged cheese and red
wine
A client with schizophrenia states, "I hear Moses calling me
constantly. He says I should leave the hospital today and save
the Pilgrims from death. Do you hear it too?" Which of the
following would be the nurse's most therapeutic response?
Correct Answer "No, I don't hear the voice. I know that you are
hearing what sounds like a voice."
A nurse is assessing a male client who recently began taking
haloperidol, which of the following findings is the highest
, priority to report to the provider. Correct Answer Neck
Spasms.
A nurse is caring for a client who has bulimia nervosa and who
has stopped purging behavior. The client tells the nurse that she
is afraid she is going to gain weight. Which of the following is
an appropriate response by the nurse? Correct Answer I
understand you have concerns about your weight, but first, let's
talk about your recent accomplishments.
A nurse observes dental deterioration when assessing a client
diagnosed with bulimia nervosa. What explains this assessment
finding? Correct Answer The emesis produced during purging
is acidic and corrodes the tooth enamel.
After the nurse has taught the client who is being discharged on
lithium (Eskalith) about the drug, which of the following client
statements would indicate that the teaching has been successful?
Correct Answer "I'll call my doctor right away for any
vomiting, severe hand tremors, or muscle weakness."
During an admission assessment, a nurse asks a client diagnosed
with schizophrenia, "Have you ever felt that certain objects or
persons have control over your behavior?" The nurse is
assessing for which type of thought disruption? Correct
Answer Delusions of influence.
Jack is a 48 years old and has been diagnosed with
schizophrenia since the age of 22. He often forgets things, looses
items, and is frequently confused. He is living in a residential
home and needs help with his ADL's and cooking for himself.