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After assessing a client with schizophrenia, the nurse suspects that the client is experiencing an anticholinergic crisis. Which of the following would the nurse most likely have assessed? Select all that apply.
- A. Dilated reactive pupils
- B. Blurred vision
- C. Ataxia
- D. Coherent speech
- E. Facial pallor
- F. Disorientation
Correct Answer: B,C,F
Rationale: Anticholinergic crisis symptoms include blurred vision (B), ataxia (C), and disorientation (F) due to excessive anticholinergic effects (e.g., from medications). Dilated pupils (A) may occur but are less specific, coherent speech (D) is unlikely, and facial pallor (E) is not typical.
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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.
A client who has a major depressive episode tells the nurse that for the past 2 weeks, he has been hearing voices and at times thinks that someone is following him. History reveals that he had these alternating symptoms before along with times when he has experienced neither of these symptoms and has been able to function adequately. The nurse interprets these findings as suggesting which of the following?
- A. Paranoid schizophrenia
- B. Undifferentiated schizophrenia
- C. Brief psychotic disorder
- D. Schizoaffective disorder
Correct Answer: D
Rationale: Schizoaffective disorder (D) combines mood episodes (depression) with psychotic symptoms (hallucinations, paranoia) that persist but allow periods of adequate functioning, matching the client?s history. Paranoid (A) and undifferentiated schizophrenia (B) lack prominent mood components, and brief psychotic disorder (C) is shorter in duration.
The nurse is interviewing a client with schizophrenia when the client begins to say, Kite, night, right, height, fright. The nurse documents this as which of the following?
- A. Clang association
- B. Stilted language
- C. Verbigeration
- D. Neologisms
Correct Answer: A
Rationale: Clang association (A) describes speech patterns where words are chosen for their sound (e.g., rhyming), as seen in the client?s list, common in schizophrenia. Stilted language (B) is overly formal, verbigeration (C) is repetitive phrases, and neologisms (D) are invented words, none of which fit.
The nurse is caring for a client in an inpatient mental health setting. The nurse notices that when the client is conversing with other clients, he repeats what they are saying word for word. The nurse interprets this finding and documents it as which of the following?
- A. Echopraxia
- B. Neologisms
- C. Tangentiality
- D. Echolalia
Correct Answer: D
Rationale: Echolalia (D) is the correct term for the client?s behavior of repeating others? words verbatim, a common symptom in schizophrenia or other psychotic disorders, reflecting impaired communication processing. Echopraxia (A) involves mimicking movements, not speech. Neologisms (B) are made-up words, and tangentiality (C) refers to responses that veer off-topic, neither of which apply here.