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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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A family member of a client diagnosed with schizoaffective disorder asks a nurse what causes the disorder. Which response by the nurse would be most appropriate?
- A. Dysfunctional family dynamics has been identified as a strong link.
- B. Research has suggested that the cause is predominately genetic.
- C. Dopamine, a substance in the brain, appears to be underactive.
- D. Studies have indicated that birth order is strongly associated with this disorder.
Correct Answer: B
Rationale: Research indicates a strong genetic component (B) in schizoaffective disorder, with heritability estimates similar to schizophrenia. Family dynamics (A) are not a primary cause, dopamine is overactive (C) in psychosis, and birth order (D) lacks evidence as a cause.
A nurse is preparing an in-service program for a group of psychiatric-mental health nurses about schizophrenia. Which of the following would the nurse include as a major reason for relapse?
- A. Lack of family support
- B. Accessibility to community resources
- C. Non-adherence to prescribed medications
- D. Stigmatization of mental illness
Correct Answer: C
Rationale: Non-adherence to prescribed medications (C) is a primary cause of relapse in schizophrenia, as antipsychotics are critical for symptom control. Lack of family support (A) and stigmatization (D) contribute indirectly, while accessibility to resources (B) is a protective factor.
A client hospitalized for treatment of schizophrenia has been receiving olanzapine (Zyprexa) for the past 2 months. The nurse would be especially alert for which of the following?
- A. Weight loss
- B. Hypertension
- C. Diarrhea
- D. Diabetes
Correct Answer: D
Rationale: Olanzapine (D) is associated with metabolic side effects, including an increased risk of diabetes due to weight gain and insulin resistance. Weight loss (A) is unlikely, hypertension (B) is less common, and diarrhea (C) is not a primary concern with olanzapine.
The nurse is caring for a hospitalized client who has schizophrenia. The client has been taking antipsychotic medications for 1 week when the nurse observes that the client?s eyes are fixed on the ceiling. The nurse interprets this finding as which of the following?
- A. Akathisia
- B. Oculogyric crisis
- C. Retrocollis
- D. Tardive dyskinesia
Correct Answer: B
Rationale: Oculogyric crisis (B) is an acute dystonic reaction characterized by fixed upward gaze, often caused by antipsychotics within days of starting treatment. Akathisia (A) involves restlessness, retrocollis (C) is neck muscle dystonia, and tardive dyskinesia (D) involves late-onset involuntary movements, none of which match the symptom.
The nurse is caring for a client who was diagnosed with schizoaffective disorder. Based on the nurse?s understanding of this disorder, the nurse develops a plan of care to address which issue as the top priority?
- A. Suicide
- B. Aggression
- C. Substance abuse
- D. Eating disorder
Correct Answer: A
Rationale: Suicide (A) is the top priority in schizoaffective disorder due to the combined risk of mood disturbances (e.g., depression) and psychosis, both of which elevate suicide risk. Aggression (B), substance abuse (C), and eating disorders (D) are concerns but less immediate unless actively present.