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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.
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All of the following are nursing diagnoses identified for a client with schizophrenia. The student nurse correctly anticipates which diagnosis will resolve when the client's negative symptoms improve?
- A. Impaired verbal communication
- B. Risk for other-directed violence
- C. Disturbed thought processes
- D. Social isolation
Correct Answer: D
Rationale: Social isolation, a negative symptom, improves with negative symptom reduction, unlike impaired communication, violence risk, or thought processes, which are positive symptom-related.
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 client with schizophrenia has returned to the clinic because of an increase in symptoms. The client reports he stopped taking his meds because he did not like the side effects. The nurse educates the client about managing uncomfortable side effects. Which of the following is included in the teaching plan?
- A. Suck on hard candy as desired
- B. Spend at least 30 minutes outside in the sun daily
- C. Use stool softeners as needed
- D. Decrease the amount of daily fluid intake
- E. Maintain a balanced calorie-controlled diet
Correct Answer: A,C,E
Rationale: Managing side effects like dry mouth (candy), constipation (stool softeners), and weight gain (diet) supports adherence, unlike increased sun exposure or reduced fluid intake.
A client diagnosed with schizophrenia is laughing and talking while sitting alone. Which of the following is the best response by the nurse?
- A. Can you share your joke with me?
- B. To sit with the client quietly until the client is ready to talk
- C. Tell me what's happening.
- D. You look lonely here. Let's join the others in the day room.
Correct Answer: C
Rationale: Asking what's happening explores the client's experience, engaging them in reality-based interaction, unlike assuming loneliness, humor, or waiting silently.
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.