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A client who has suspicion has been placed in a room with a roommate. The night nurse reports that this client has been awake for the past 3 nights. The likely explanation for his wakefulness is which of the following?
- A. He is fearful of what his roommate might do to him while he sleeps.
- B. He is a light sleeper and unaccustomed to a roommate.
- C. He is watching for an opportunity to escape.
- D. He is worrying about his family problems.
Correct Answer: A
Rationale: Suspicion in schizophrenia often causes fear of harm from others, like a roommate, making it the most likely reason for wakefulness over other explanations.
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During the nursing assessment, a client describes constantly hearing voices mumbling in the background. The client denies that the voices are telling him to do anything harmful. The nurse documents that the client is experiencing which of the following?
- A. Command hallucinations
- B. Auditory hallucinations
- C. Olfactory hallucinations
- D. Gustatory hallucinations
Correct Answer: B
Rationale: Hearing non-command voices indicates auditory hallucinations, the most common type in schizophrenia, distinct from command, olfactory, or gustatory hallucinations.
A client who has schizophrenia is having a conversation with the nurse suddenly stops talking in the middle of a sentence. The client is experiencing which type of thought disruption?
- A. Thought withdrawal
- B. Thought insertion
- C. Thought blocking
- D. Thought broadcasting
Correct Answer: C
Rationale: Sudden cessation of speech indicates thought blocking, unlike thought withdrawal (belief others take thoughts), insertion (belief others place thoughts), or broadcasting (belief others hear thoughts).
The nurse enters the room of a client with schizophrenia the day after he has been admitted to an inpatient setting and says, 'I would like to spend some time talking with you.' The client stares straight ahead and remains silent. The best response by the nurse is,
- A. I can see you want to be alone. I'll come back another time.
- B. If you don't need to talk right now, I'll just sit here for a few minutes.
- C. I've got some other things I can do now. I hope you'll feel like talking later.
- D. You would feel better if you would tell me what you're thinking.
Correct Answer: B
Rationale: Sitting quietly shows acceptance and builds trust, supporting the client's limited tolerance for interaction, unlike leaving or assuming feelings.
A student nurse is having a first experience in an inpatient psychiatric unit and is frightened by the behaviors of the clients with schizophrenia. The student should take which of the following actions to deal with fear?
- A. Express fear to the psychiatrist during rounds
- B. Pretend to not be afraid
- C. Stay in an open area while talking with the clients
- D. Insist that the clients behave appropriately
Correct Answer: C
Rationale: Staying in an open area ensures safety, addressing fear constructively, unlike pretending, expressing fear publicly, or demanding client behavior changes.
A client with schizophrenia is reluctant to take his prescribed oral medication. The most therapeutic response by the nurse to this refusal is,
- A. I can see that you're uncomfortable now, so we can wait until tomorrow.
- B. If you refuse these pills, you'll have to get an injection.
- C. What is it about the medicine that you don't like?
- D. You know you have to take this medicine for your own good.
Correct Answer: C
Rationale: Exploring reasons for medication refusal addresses barriers to compliance, fostering collaboration, unlike threats, delays, or non-therapeutic insistence.