Nokea
A client with schizophrenia is admitted to the inpatient unit. He does not speak when spoken to but has been observed talking to himself on occasion. What would be the priority objective at this time?
- A. The client will begin talking with other clients
- B. The client will express his feelings freely
- C. The client will increase his socialization with others
- D. The client will increase his reality orientation
Correct Answer: D
Rationale: Increasing reality orientation is the priority to ground the client before addressing socialization or emotional expression, given his current withdrawn state.
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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.
The client with schizophrenia is experiencing delusions. Which of the following is the most appropriate 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: Presenting reality while inquiring about the client's experience avoids reinforcing delusions and promotes engagement, unlike dismissing or confronting the delusion directly.
A person suffering from schizophrenia has little emotional expression when interacting with others. The nurse would document the client's affect as which of the following?
- A. Flat
- B. Blunt
- C. Bright
- D. Inappropriate
- E. Pleasant
Correct Answer: A,B
Rationale: Flat or blunted affect, showing little to no emotional expression, is typical in schizophrenia, unlike bright, inappropriate, or pleasant affect.
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.
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).