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NSG 322 Week 8 Socrative Answer Key
Behavioral Health Nursing (NSG-322)
Grand Canyon University
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NSG 322 Week 8 Socrative Answer Key – Schizophrenia Spectrum DO – Part 2 1. A patient smiles broadly at the nurse and says, "Look at my clean teeth. I brushed them with scouring powder because the label said, "it brightens and whitens everything." Which term should the nurse include when documenting this encounter? a. Circumstantiality b. Concrete thinking c. Poverty of speech d. Associative looseness i b. Concrete thinking refers to literal interpretations, with an inability to comprehend abstract concepts. 2. A patient diagnosed with schizophrenia says, "I hear the voices every day. They always say bad things about me." Which action by the nurse has the highest priority? a. Assess the patient for suicidal thinking and plans. b. Review the patient's medication regimen and adherence. c. Educate the patient about symptoms associated with schizophrenia. d. Suggest distracters for the patient to use when auditory hallucinations occur. i a. The daily experience of negativity creates a scenario in which the risk for suicide is high. Depressive symptoms occur frequently in schizophrenia. Suicide is the leading cause of premature death in this population. 3. Three days after beginning a new regime of haloperidol (Haldol), the nurse observes that a hospitalized patient is drooling, has stiff and extended extremities, and skin that is damp and hot to the touch. The patient has difficulty responding verbally to the nurse. What is the nurse's correct analysis and action in this situation? a. A seizure is occurring; place the patient in a lateral recumbent position and monitor. b. Serotonin syndrome has developed; place an intravenous line and rapidly infuse D 1/2 normal saline (NS). c. Neuroleptic malignant syndrome (NMS) has developed; prepare the patient for immediate transfer to a medical unit. d. An acute dystonic reaction is occurring; promptly administer an intramuscular injection of diphenhydramine (Benadryl). i c. Neuroleptic malignant syndrome (NMS) occurs in persons who have taken antipsychotic agents and usually begins early in the course of therapy. It is characterized by a decreased level of consciousness, greatly increased muscle tone, and autonomic dysfunction, including hyperpyrexia, labile hypertension, tachycardia, tachypnea, diaphoresis, and drooling. Treatment consists of early detection, discontinuation of the antipsychotic agent, management of fluid balance, reduction of temperature, and monitoring for complications. Treatment of this problem should occur in a medical unit. THIS IS CONSIDERED A MEDICAL EMERGENCY. 4. A nurse begins a therapeutic relationship with a patient diagnosed with schizophrenia. The patient has severe paranoia. Which comment by the nurse is most appropriate? a. "Let's begin by talking about the goals you have for yourself." b. "I understand that you have problems with fear and suspiciousness of others."
c. "As you get to know me better, I hope you will feel more comfortable talking to me." d. "I am part of your treatment team. Our goal is to help stabilize your symptoms." i c. Paranoia causes an inability to trust the actions of others. Therapeutic strategies should focus on lowering the patient's anxiety and decreasing defensive patterns. The application of principles for dealing with paranoia is helpful for establishing trust and rapport. 5. A patient diagnosed with schizophrenia complains to the nurse about persistent feelings of restlessness and says, "I feel like I need to move all the time." What is the nurse's next action? a. Add an activity group to the patient's plan of care. b. Assess the patient for other extrapyramidal symptoms (EPS). c. Perform a full mental status evaluation (MSE) of the patient. d. Educate the patient about the psychomotor agitation associated with schizophrenia. i b. The patient's comments suggest that akathisia, which is an extrapyramidal symptom (EPS), is occurring. The nurse should assess the patient for other indicators of this side effect of antipsychotic medication. 6. A client diagnosed with schizophrenia is admitted to an acute care psychiatric unit. Which clinical findings indicate positive signs and symptoms associated with schizophrenia? a. Withdrawal, poverty of speech, inattentiveness b. Flat affect, decreased spontaneity, asocial behavior c. Hypomania, labile mood swings, episodes of euphoria d. Hyperactivity, auditory hallucinations, loose associations i d. Hyperactivity, auditory hallucinations, and loose associations are positive symptoms associated with schizophrenia; positive symptoms reflect a distortion or excess of normal function. 7. As a nurse enters a room and approaches a client diagnosed with schizophrenia, the client states, "Get out of here before I hit you - go away." The nurse concludes that this aggressive behavior is probably related to the fact that the client felt: a. that voices were directing the behavior. b. trapped when the nurse walked into the room. c. afraid of doing harm to the nurse if the nurse came closer. d. that the nurse was similar to someone who was previously frightening. i b. Clients acutely ill with schizophrenia frequently do not trust others; feeling trapped may be frightening causing them to lash out. 8. During the admission procedure, a client appears to be responding to voices. The client cries out at intervals, "No, no, I didn't kill him. You know the truth; tell that police officer. Please help me!" What is the nurse's most appropriate response? a. Sit quietly and not respond to the client's statement. b. Listen attentively and assume a facial expression of disbelief. c. Respond by saying, "I want to help you; I realize you must be very frightened."
NSG 322 Week 8 Socrative Answer Key
Course: Behavioral Health Nursing (NSG-322)
University: Grand Canyon University
