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A client asks the nurse upon discharge, 'What should I do if I forget to take my medicine?' The nurse should explain to the client which of the following?
- A. Just double the dose next time it is scheduled.
- B. Skip that dose and resume your regular with the next dose.
- C. Don't miss doses, or you will not maintain therapeutic drug levels.
- D. If you remember within 3 to 4 hours later than it is due, take it then. If you remember more than 4 hours after it was due, do not take that dose.
Correct Answer: D
Rationale: Taking a missed dose within 3-4 hours maintains therapeutic levels, but skipping it if later avoids disruption, unlike doubling doses or vague warnings.
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The client with schizophrenia tells the nurse that rats have started to eat his brain. The best response by the nurse would be.
- A. Have you discussed this with your physician?
- B. How could that be possible?
- C. You cannot have rats in your brain.
- D. You look OK to me.
Correct Answer: A
Rationale: Referring to the physician for a new symptom like a delusion prompts potential medication review, unlike defensive, dismissive, or non-therapeutic responses.
The nurse is preparing a client with schizophrenia for discharge. The nurse asks the client, 'How are you going to care for yourself at home?' The purpose of the nurse's question is to assess the client's
- A. Self concept
- B. Judgment
- C. Insight
- D. Social support system
Correct Answer: C
Rationale: Asking about self-care plans assesses insight, the client's awareness of their illness and ability to manage it, unlike self-concept, judgment, or social support.
A client with schizophrenia reads the advice column in the newspaper daily. When asked why the client is so interested in the advice column, the client replies, 'This person is my guide and tells me what I must do every day.' The nurse would best describe this type of thinking as which of the following?
- A. Referential delusion
- B. Grandiose delusion
- C. Thought insertion
- D. Personalization
Correct Answer: A
Rationale: Believing the advice column has personal significance indicates a referential delusion, unlike grandiose delusions (exaggerated self-importance), thought insertion, or personalization.
All of the following are included in the plan of care for a client with schizophrenia. Which nursing intervention should the nurse perform first when caring for this client?
- A. Observe for signs of fear or agitation
- B. Maintain reality through frequent contact
- C. Encourage to participate in the treatment milieu
- D. Assess community support systems
Correct Answer: A
Rationale: Observing for fear or agitation prioritizes safety, addressing potential escalation before other interventions like reality orientation or social participation.
A client with schizophrenia is seen sitting alone and talking out loud. Suddenly, the client stops and turns as if listening to someone. The nurse approaches and sits down beside the client. Which of the following is the best initial response by the nurse?
- A. I can see you want to be alone. I'll come back another time.
- B. What are you hearing and seeing?
- C. I don't hear or see anyone else, what are you hearing and seeing?
- D. I can tell you are hearing voices but they are not real.
Correct Answer: C
Rationale: Asking what the client is experiencing while presenting reality validates their perception and encourages discussion, unlike dismissing, assuming, or denying the experience.