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A college freshman is admitted to the hospital with a diagnosis of schizophrenia. Friends reported that she had been in her room for 2 days in a trance-like state, not eating nor speaking to anyone. Which of the following is the highest priority for this client?
- A. Assessing fluid intake and output
- B. Completing an assessment of mental status
- C. Obtaining more data about her college experiences
- D. Providing for adequate rest
Correct Answer: A
Rationale: Assessing fluid intake and output prioritizes physiologic homeostasis, critical for a client not eating, over mental status, rest, or background data.
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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.
All of the following are included in the plan of care for a client with schizophrenia. Which nursing intervention should the nurse perform first when caring for this client?
- A. Observe for signs of fear or agitation
- B. Maintain reality through frequent contact
- C. Encourage to participate in the treatment milieu
- D. Assess community support systems
Correct Answer: A
Rationale: Observing for fear or agitation prioritizes safety, addressing potential escalation before other interventions like reality orientation or social participation.
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 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 with schizophrenia reads the advice column in the newspaper daily. When asked why the client is so interested in the advice column, the client replies, 'This person is my guide and tells me what I must do every day.' The nurse would best describe this type of thinking as which of the following?
- A. Referential delusion
- B. Grandiose delusion
- C. Thought insertion
- D. Personalization
Correct Answer: A
Rationale: Believing the advice column has personal significance indicates a referential delusion, unlike grandiose delusions (exaggerated self-importance), thought insertion, or personalization.