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A client has been diagnosed with schizophrenia. Assessment reveals that the client lives alone. His clothing is disheveled, his hair is uncombed and matted, and his body has a strange odor. During an interview, the client?s family voices a desire for the client to live with them when he is discharged. Based on the assessment findings, which nursing diagnosis would be the priority?
- A. Ineffective Role Performance related to symptoms of schizophrenia.
- B. Social Isolation related to auditory hallucinations.
- C. Dysfunctional Family Processes related to psychosis.
- D. Bathing Self-Care Deficit related to symptoms of schizophrenia.
Correct Answer: D
Rationale: Bathing Self-Care Deficit (D) is the priority nursing diagnosis, as the client?s disheveled appearance, matted hair, and body odor indicate an immediate inability to maintain personal hygiene, which affects health and social integration. Ineffective Role Performance (A) and Social Isolation (B) are relevant but secondary, and Dysfunctional Family Processes (C) is not supported by the family?s supportive stance.
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While interviewing a client diagnosed with a delusional disorder, the client states, I have this really strange odor coming out of my mouth. I stop to brush my teeth almost every hour and then rinse with mouthwash every half hour to get rid of this smell. I?ve seen so many doctors, and they can?t tell me what?s wrong. The nurse interprets the client?s statement as reflecting which type of delusion?
- A. Erotomanic
- B. Grandiose
- C. Somatic
- D. Jealous
Correct Answer: C
Rationale: The client?s belief in a persistent, unexplained mouth odor reflects a somatic delusion (C), focusing on bodily concerns. Erotomanic (A) involves romantic beliefs, grandiose (B) involves inflated self-worth, and jealous (D) involves infidelity, none of which apply.
A nursing instructor is developing a class lecture that compares and contrasts schizoaffective disorder with schizophrenia. When describing one of the differences between these two diagnoses, which of the following would the instructor include as reflecting schizoaffective disorder?
- A. It is episodic in nature.
- B. It involves difficulties with self-care.
- C. It has less severe hallucinations.
- D. It is associated with a lower suicide risk.
Correct Answer: A
Rationale: Schizoaffective disorder (A) is characterized by episodic mood disturbances (depressive or manic) alongside psychotic symptoms, unlike the more persistent psychotic symptoms in schizophrenia. Self-care difficulties (B) and hallucination severity (C) are not distinguishing features, and suicide risk (D) is not necessarily lower.
The nurse is assessing a newly admitted client diagnosed with schizoaffective disorder. The nurse assesses the client?s level of anxiety and reactions to stressful situations, obtaining this information for which reason?
- A. To help determine the client?s outcomes after treatment
- B. To help identify whether or not the client?s mental competency is intact
- C. To act as a predictor of the client?s risk for a suicide attempt
- D. To provide a basis for evaluating the client?s social skills
Correct Answer: C
Rationale: Assessing anxiety and stress reactions (C) in schizoaffective disorder helps predict suicide risk, as heightened anxiety can exacerbate mood and psychotic symptoms. Outcomes (A), competency (B), and social skills (D) are less directly tied to this assessment.
The nurse is caring for a client in an inpatient mental health setting. The nurse notices that when the client is conversing with other clients, he repeats what they are saying word for word. The nurse interprets this finding and documents it as which of the following?
- A. Echopraxia
- B. Neologisms
- C. Tangentiality
- D. Echolalia
Correct Answer: D
Rationale: Echolalia (D) is the correct term for the client?s behavior of repeating others? words verbatim, a common symptom in schizophrenia or other psychotic disorders, reflecting impaired communication processing. Echopraxia (A) involves mimicking movements, not speech. Neologisms (B) are made-up words, and tangentiality (C) refers to responses that veer off-topic, neither of which apply here.
A client with schizoaffective disorder is prescribed clozapine to treat her symptoms. Which of the following instructions would the nurse provide?
- A. Keep a record of how often and how long you experience the side effect of dry mouth.
- B. Monitor your urinary output and notify your doctor if your urine changes color.
- C. Keep an eye on your weight, and if you gain weight rapidly, notify your doctor.
- D. If you experience any drowsiness, discontinue taking this medication.
Correct Answer: C
Rationale: Clozapine (C) is associated with significant weight gain, a metabolic side effect requiring monitoring and reporting if rapid. Dry mouth (A) is minor, urine color changes (B) are not typical, and discontinuing for drowsiness (D) is incorrect without medical guidance.