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A client with schizophrenia tells the nurse, I?m being watched constantly by the FBI because of my job. Which response by the nurse would be most appropriate?
- A. Tell me more about how you are being watched.
- B. It must be frightening to feel like you?re always been watched.
- C. You?re not being watched; it?s all in your mind.
- D. You are experiencing a delusion because of your illness.
Correct Answer: B
Rationale: Empathizing with the client?s fear (B) validates their emotions without reinforcing the delusion, fostering trust. Asking for more details (A) may entrench the delusion, while dismissing (C) or labeling it (D) could alienate the client.
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The nurse is caring for a client who has been taking clozapine (Clozaril) for 2 weeks. The client tells the nurse, My throat is sore, and I feel weak. The nurse assesses the client?s vital signs and finds that the client has a fever. The nurse notifies the physician, expecting an order to obtain which laboratory test?
- A. A white blood cell count
- B. Liver function studies
- C. Serum potassium level
- D. Serum sodium level
Correct Answer: A
Rationale: Clozapine (A) carries a risk of agranulocytosis, a potentially life-threatening drop in white blood cells, presenting with symptoms like sore throat, weakness, and fever. Monitoring white blood cell counts is critical. Liver function (B), potassium (C), and sodium (D) levels are less relevant to these symptoms.
After teaching a class on antipsychotic agents, the instructor determines that the teaching was successful when the class identifies which of the following as an example of a second-generation antipsychotic agent?
- A. Fluphenazine (Prolixin)
- B. Thiothixene (Navane)
- C. Quetiapine (Seroquel)
- D. Chlorpromazine (Thorazine)
Correct Answer: C
Rationale: Quetiapine (C) is a second-generation (atypical) antipsychotic, effective for schizophrenia with fewer extrapyramidal side effects. Fluphenazine (A), thiothixene (B), and chlorpromazine (D) are first-generation (typical) antipsychotics, associated with higher side effect risks.
When assessing a client for possible disordered water balance, the nurse checks the client?s urine specific gravity. Which result would lead the nurse to suspect that the client is experiencing severe disordered water balance?
- A. 1.02
- B. 1.011
- C. 1.005
- D. 1.002
Correct Answer: D
Rationale: A urine specific gravity of 1.002 (D) is extremely low, indicating overly dilute urine, consistent with severe disordered water balance (e.g., psychogenic polydipsia). Normal range is 1.010?1.030, so 1.020 (A) and 1.011 (B) are closer to normal, and 1.005 (C) is less severe.
The nurse is caring for a client who was just admitted with a diagnosis of schizoaffective disorder with depression. Which agent would the nurse anticipate as being prescribed for this client?
- A. Lithium
- B. Haloperidol
- C. Chlorpromazine
- D. Clozapine
Correct Answer: D
Rationale: Clozapine (D) is effective for schizoaffective disorder, addressing both psychotic and mood symptoms, especially in treatment-resistant cases. Lithium (A) is primarily for bipolar disorder, and haloperidol (B) and chlorpromazine (C) are less effective for mood components.
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.