Psychiatric Nursing Practice Test 8 (Practice Mode)

Rationale: Waxy flexibility, the ability to assume and maintain awkward or uncomfortable positions for long periods, is characteristic of catatonic schizophrenia. Clients commonly remain in these awkward positions until someone repositions them. Clients with dependency problems may demonstrate suggestibility, a response pattern in which one easily agrees to the ideas and suggestions of others rather than making independent judgments. Negativity (for example, resistance to being moved or being asked to cooperate) and retardation (slowed movement) also occur in catatonic clients.

Rationale: A delusion of grandeur is a false belief that one is highly important or famous. A delusion of persecution is a false belief that one is being persecuted. A delusion of reference is a false belief that one is connected to events unrelated to oneself or a belief that one is responsible for the evil in the world.

Rationale: An antipsychotic agent, such as haloperidol, can cause muscle spasms in the neck, face, tongue, back, and sometimes legs as well as torticollis (twisted neck position). The nurse should be aware of these adverse reactions and assess for related reactions promptly. Although posturing may occur in clients with schizophrenia, it isn't the same as neck and jaw spasms. Having the client relax can reduce tension-induced muscle stiffness but not drug-induced muscle spasms. When a client develops a new sign or symptom, the nurse should consider an adverse drug reaction as the possible cause and obtain treatment immediately, rather than have the client wait.

Rationale: Option B is correct because allowing a paranoid client to open his medication can help reduce suspiciousness. Option A is incorrect because the client doesn't know that it's his medication and he's obviously suspicious. Telling the client not to worry or ignoring the comment isn't supportive and doesn't offer reassurance.

Rationale: The positive symptoms of schizophrenia are distortions of normal functioning. Option A lists the positive symptoms of schizophrenia. A flat affect, alogia, apathy, avolition, and anhedonia refer to the negative symptoms. Negative symptoms list the diminution or loss of normal function

Rationale: By treating psychosis, haloperidol, an antipsychotic drug, decreases agitation. Haloperidol is used to treat dyskinesia in clients with Tourette syndrome and to treat dementia in elderly clients. Tardive dyskinesia may occur after prolonged haloperidol use; the client should be monitored for this adverse reaction.

Rationale: The Diagnostic and Statistic Manual of Mental Disorders, 4th edition, defines schizophrenia as a disturbance in multiple psychological processes that affects thought content and form, perception, affect, sense of self, volition, relationship to the external world, and psychomotor behavior. Loss of identity sometimes occurs but is only one characteristic of the disorder. Multiple personalities typify multiple personality disorder, a dissociative personality disorder. Mood disorders are commonly accompanied by increased or decreased self-esteem. Schizophrenia doesn't cause a disturbance in sensorium, although the client may exhibit confusion, disorientation, and memory impairment during the acute phase.

Rationale: Because haloperidol can cause photosensitivity and precipitate severe sunburn, the nurse should instruct the client to apply a sunscreen before exposure to the sun. The nurse also should teach the client to take haloperidol with meals — not 1 hour before — and should instruct the client not to decrease or increase the dosage unless the physician orders it

Rationale: Benztropine is an anticholinergic drug administered to reduce extrapyramidal adverse effects in the client taking antipsychotic drugs. It works by restoring the equilibrium between the neurotransmitters acetylcholine and dopamine in the central nervous system (CNS). Dantrolene, a hydantoin drug that reduces the catabolic processes, is administered to alleviate the symptoms of neuroleptic malignant syndrome, a potentially fatal adverse effect of antipsychotic drugs. Clonazepam, a benzodiazepine drug that depresses the CNS, is administered to control seizure activity. Diazepam, a benzodiazepine
drug, is administered to reduce anxiety.

Rationale: Hallucinations are visual, auditory, gustatory, tactile, or olfactory perceptions that have no basis in reality. Delusions are false beliefs, rather than perceptions, that the client accepts as real. Loose associations are rapid shifts among unrelated ideas. Neologisms are bizarre words that have meaning only to the client.

Rationale: A reliable genetic marker hasn't been determined for schizophrenia. However, studies of twins and adopted siblings have strongly implicated a genetic predisposition. Since the mid-19th century, excessive dopamine activity in the brain has also been suggested as a causal factor. Communication and the family system have been studied as contributing factors in the development of schizophrenia. Therefore, a combination of biological, psychological,
and environmental factors are thought to cause schizophrenia.

The client with schizophrenia is commonly socially isolated and withdrawn; therefore, having the client spend more time by himself wouldn't be a desirable outcome. Rather, a desirable outcome would specify that the client spend more time with other clients and staff on the unit. Delusions are false personal beliefs. Reducing or eliminating delusional thinking using talking therapy and antipsychotic medications would be a desirable outcome. Protecting the client and others from harm is a desirable client outcome achieved by close observation, removing any dangerous objects, and administering medications. Because the client with schizophrenia may have difficulty meeting his or her own self-care needs, fostering the ability to perform self-care independently is a desirable client outcome.

Rationale: This response may diffuse the client's anger by helping to maintain a therapeutic relationship and addressing the client's feelings. Option A wouldn't address the client's anger. Option B is incorrect because the client with a borderline personality disorder blames others for things that happen, so apologizing reinforces the client's misconceptions. The nurse can't promise that a delay will never occur again, as in option D, because such matters are outside the nurse's control.

Rationale: Risperdal has a lower incidence of extrapyramidal effects than the typical antipsychotics. Risperdal does produce anticholinergic effects and neuroleptic malignant syndrome can occur. Photosensitivity isn't an advantage.

Rationale: Clozapine can cause life-threatening neutropenia or granulocytopenia. To detect this adverse reaction, a WBC count should be performed weekly. Hepatitis, infection, and systemic dermatitis aren't adverse reactions of clozapine therapy.

Rationale: A sore throat and fever are indications of an infection caused by agranulocytosis, a potentially life-threatening complication of clozapine. Because of the risk of agranulocytosis, white blood cell (WBC) counts are necessary weekly, not monthly. If the WBC count drops below 3,000/µl, the medication must be stopped. Hypotension may occur in clients taking this medication. Warn the client to stand up slowly to avoid dizziness from orthostatic hypotension. The medication should be continued, even when symptoms have been controlled. If the medication must be stopped, it should be slowly tapered over 1 to 2 weeks and only under the supervision of a physician.

* A and B are both correct in taking HALDOL.

Rationale: Although most phenothiazines produce some effects within minutes to hours, their antipsychotic effects may take several weeks to appear.

Rationale: Benztropine is an anticholinergic medication, administered to reduce the extrapyramidal adverse effects of chlorpromazine and other antipsychotic medications. Benztropine doesn't reduce psychotic symptoms, relieve anxiety, or control nausea and vomiting.

Rationale: This response addresses the client's underlying fears without feeding the delusion. Refuting the client's delusion, as in option B, would increase anxiety and reinforce the delusion. Asking the client to elaborate on the delusion, as in option C, would also reinforce it. Voicing disbelief about the delusion, as in option D, wouldn't help the client deal with underlying fears

Rationale: An adverse reaction to phenothiazines, tardive dyskinesia refers to choreiform tongue movements that commonly are irreversible and may interfere with speech. Dystonia refers to involuntary contraction of a muscle group. Akathisia is restlessness or inability to sit still. Pseudoparkinsonism describes a group of symptoms that mimic those of Parkinson's disease.

Rationale: Avolition refers to impairment in the ability to initiate goal-directed activity. Word salad is when a group of words are put together in a random fashion without logical connection. Tangential is where a person never gets to the point of the communication. Perseveration is when a person repeats the same word or idea in response to different questions.

Rationale: Increasing the amount of auditory stimulation, such as by listening to music through headphones, may make it easier for the client to focus on external sounds and ignore internal sounds from auditory hallucinations. Option A would make it harder for the client to ignore the hallucinations. Talking about the voices, as in option C, would encourage the client to focus on them. Option D is incorrect because exercise alone wouldn't provide enough auditory stimulation to drown out the voices.

Rationale: The nurse must question this order immediately. Thioridazine (Mellaril) has an absolute dosage ceiling of 800 mg/day. Any dosage above this level places the client at high risk for toxic pigmentary retinopathy, which can't be reversed. As written, the order allows for administering more than the maximum 800 mg/day; it should be corrected immediately, before the client's health is jeopardized.

Rationale: Dystonia, a common extrapyramidal reaction to fluphenazine decanoate, manifests as muscle spasms in the tongue, face, neck, back, and sometimes the legs. Akinesia refers to decreased or absent movement; akathisia, to restlessness or inability to sit still; and tardive dyskinesia, to abnormal muscle movements, particularly around the mouth.

Rationale: By establishing a one-on-one relationship, the nurse helps the client learn how to interact with people in new situations. The other options are appropriate but should take place only after the nurse-client relationship is established.

Rationale: Propranolol is a potent beta-adrenergic blocker and produces a sedating effect; therefore, it's used to treat antipsychotic induced akathisia and anxiety. Lithium (Lithobid) is used to stabilize clients with bipolar illness. Antipsychotics are used to treat delusions. Some antidepressants have been effective in treating OCD.

Rationale: Option C is the most therapeutic response because it orients the client to reality. Options A and B are condescending. Option D sounds punitive and could embarrass the client.

Rationale: Bruising may indicate blood dyscrasias, so notifying the physician about increased bruising is very important. Don't double the dose. This drug doesn't irritate the stomach, and weight gain isn't a problem.

Rationale: Because a client with catatonic schizophrenia can't meet physical needs independently, the nurse must provide for all of these needs, including adequate food and fluid intake, exercise, and elimination. This client is incapable of expressing concerns; however, the nurse should try to verbalize the message conveyed by the client's nonverbal behavior. Lithium is used to treat mania, not catatonic schizophrenia. Despite the client's mute, unresponsive state, the nurse should provide nonthreatening stimulation and should spend time with the client, not leave the client alone all the time. Although aware of the environment, the client doesn't interact with it actively; the nurse's support and presence can be reassuring.

Rationale: This client's behaviors are typical of histrionic personality disorder, which is marked by excessive emotionality and attention seeking. The client constantly seeks and demands attention, approval, or praise; may be seductive in behavior, appearance, or conversation; and is uncomfortable except when she is the center of attention. Typically, a client with paranoid personality disorder is suspicious, cold, hostile, and argumentative. Avoidant personality disorder is characterized by anxiety, fear, and social isolation. Borderline personality disorder is characterized by impulsive, unpredictable behavior and unstable, intense interpersonal relationships.

Rationale: The client needs to be informed of the activity and when it will be done. Giving the client choices isn't desirable because he can be manipulative or refuse to do anything. Negotiating and preparing the client ahead of time also isn't therapeutic with this type of client because he may not want to perform the activity.

Rationale: Shortly after phenothiazine administration, a quieting and calming effect occurs, but the client is easily aroused, alert, and responsive and has good motor coordination.

Rationale: Decreased libido, retrograde ejaculation, and gynecomastia are all hormonal effects that can occur with antipsychotic medications. Reassure the client that the effects can be reversed or that changing medication may be possible. Polydipsia, akinesia, and dysphasia aren't hormonal effects.

Rationale: By acknowledging the client's fears, the nurse can arrange to meet the client's hygiene needs in another way. Because these fears are real to the client, providing a demonstration of reality (as in option A) wouldn't be effective at this time. Options B and C would violate the client's rights by shaming or embarrassing the client.

Rationale: Because family members of a client with schizophrenia face difficult situations and great stress, the nurse should inform them of support services that can help them cope with such problems. The nurse should also teach them that medication can't prevent relapses and that environmental stimuli may precipitate symptoms. Although stress can trigger symptoms, the nurse shouldn't make the family feel responsible for relapses (as in option D).

Rationale: Nursing assessment of a psychotic client should include careful inquiry about and observation of the client's thinking, perceiving, symbolizing, and decision-making skills and abilities. Assessment of such a client typically reveals alterations in thought content and process, perception, affect, and psychomotor behavior; changes in personality, coping, and sense of self; lack of self-motivation; presence of psychosocial stressors; and degeneration of adaptive functioning. Although assessing communication processes, affect, behavior, and psychomotor activity would reveal important information about the client's condition, the nurse should concentrate on determining whether the client is hallucinating by assessing thought processes and decision-making ability.

Rationale: Antipsychotic medications exert an effect on brain neurotransmitters that lowers the seizure threshold and can, therefore, increase the risk of seizure activity. Antipsychotics don't affect insulin production or coagulation time. Heart failure isn't an adverse effect ofantipsychotic agents

Rationale: Fluphenazine decanoate is a long-acting antipsychotic agent given by injection. Because it has a 4-week duration of action, it's commonly prescribed for outpatients with a history of medication noncompliance. Chlorpromazine, also an antipsychotic agent, must be administered daily to maintain adequate plasma levels, which necessitates compliance with the dosage schedule. Imipramine, a tricyclic antidepressant, and lithium carbonate, a mood stabilizer, are rarely used to treat clients with chronic schizophrenia.

Rationale: According to the DSM-IV, schizoaffective disorder refers to clients suffering from schizophrenia with elements of a mood disorder, either mania or depression. The prognosis is generally better than for the other types of schizophrenia, but it's worse than the prognosis for a mood disorder alone. Option A is incorrect because personality disorders and psychotic illness aren't listed together on the same axis. Option C is incorrect because schizophrenia is a major thought disorder and the question asks for elements of another disorder. Clients with schizoaffective disorder aren't suffering from schizophrenia and an amnestic disorder.

Rationale: Lithium carbonate, an antimania drug, is used to treat clients with cyclical schizoaffective disorder, a psychotic disorder once classified under schizophrenia that causes affective symptoms, including maniclike activity. Lithium helps control the affective component of this disorder. Phenelzine is a monoamine oxidase inhibitor prescribed for clients who don't respond to other antidepressant drugs such as imipramine. Chlordiazepoxide, an antianxiety agent, generally is contraindicated in psychotic clients. Imipramine, primarily considered an antidepressant agent, is also used to treat clients with agoraphobia and those undergoing cocaine detoxification.

Rationale: Bipolar illness is characterized by mood swings from profound depression to elation and euphoria. Delusions of grandeur along with pressured speech are common symptoms of mania. Schizophrenia doesn't exhibit mood swings from depression to euphoria. Paranoia is characterized by unrealistic suspiciousness and is often accompanied by grandiosity. OCD is a preoccupation with rituals and rules.

Rationale: This client's paranoid ideation indicates difficulty trusting others. The stage of autonomy versus shame and doubt deals with separation, cooperation, and self-control. Generativity versus stagnation is the normal stage for this client's chronologic age. Integrity versus despair is the stage for accepting the positive and negative aspects of one's life, which would be difficult or impossible for this client.

Rationale: Retinal pigmentation may occur if the thioridazine dosage exceeds 800 mg per day. The other options don't occur as a result of exceeding this dose.

Rationale: Sharing a benign, nonthreatening, personal fact or feeling helps the nurse establish rapport and encourages the client to confide in the nurse. The nurse can't know how the client feels. Telling the client otherwise, as in option B, would justify the suspicions of a paranoid client; furthermore, the client relies on the nurse to interpret reality. Option C is incorrect because it focuses on the nurse's feelings, not the client's. Option D wouldn't help establish rapport or encourage the client to confide in the nurse

Rationale: The nurse should set limits on client behavior to ensure a comfortable environment for all clients. The nurse should accept hostile or quarrelsome client outbursts within limits without becoming personally offended, as in option A. Option B is incorrect because it implies that the client's actions reflect feelings toward the staff instead of the client's own misery. Judgmental remarks, such as option D, may decrease the client's self-esteem.

Rationale: Antipsychotic medications may cause neutropenia and granulocytopenia, life-threatening blood dyscrasias, that warrant a nursing diagnosis of Ineffective protection related to blood dyscrasias. These medications also have anticholinergic effects, such as urine retention, dry mouth, and constipation. Urinary frequency isn't an approved nursing diagnosis. Although antipsychotic medications may cause sedation, they don't severely decrease the level of consciousness, eliminating option C. These drugs don't cause electrolyte disturbances, eliminating option D.

Rationale: When administered with any phenothiazine, droperidol may increase the risk of extrapyramidal effects. The other options are incorrect

Rationale: An antiparkinsonian agent, such as amantadine, may be used to control pseudoparkinsonism; diphenhydramine or benztropine may be used to control other extrapyramidal effects. Phenytoin is used to treat seizure activity.

Rationale: For this client, the highest-priority nursing diagnosis is Anxiety (severe to panic-level), manifested by the client's extreme withdrawal and attempt to protect himself from the environment. The nurse must act immediately to reduce anxiety and protect the client and others from possible injury. Impaired verbal communication, manifested by noncommunicativeness; Disturbed thought processes, evidenced by inability to understand the situation; and Self-care deficient: Dressing/grooming, evidenced by a disheveled appearance, are appropriate nursing diagnoses but aren't the highest priority