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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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A client with schizoaffective disorder is having difficulty adhering to the medication regimen that requires the use of several agents. The client also is experiencing several side effects contributing to this nonadherence. The physician plans to change the client?s medication. Which agent would the nurse anticipate that the physician would prescribe?
- A. Lithium
- B. Aripiprazole
- C. Clozapine
- D. Olanzapine
Correct Answer: B
Rationale: Aripiprazole (B) is a second-generation antipsychotic with a favorable side effect profile and efficacy for schizoaffective disorder, improving adherence. Lithium (A) is for mood stabilization, clozapine (C) is for treatment-resistant cases, and olanzapine (D) has more side effects.
A client is being released from the inpatient psychiatric unit with a diagnosis of schizophrenia and treatment with antipsychotic medications. After teaching the client and family about managing the disorder, the nurse determines that the teaching was effective when they state which of the following should be reported immediately?
- A. Elevated temperature
- B. Tremor
- C. Decreased blood pressure
- D. Weight gain
Correct Answer: A
Rationale: Elevated temperature (A) could indicate a serious side effect like neuroleptic malignant syndrome or infection (e.g., agranulocytosis with clozapine), requiring immediate reporting. Tremor (B), decreased blood pressure (C), and weight gain (D) are less urgent, though they warrant monitoring.
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 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.
The nurse is preparing to interview a client who has a delusional disorder. Which of the following would the nurse expect?
- A. Cognitive impairment
- B. Normal behavior
- C. Labile affect
- D. Evidence of motor symptoms
Correct Answer: B
Rationale: Clients with delusional disorder typically exhibit normal behavior (B) outside their specific delusions, with intact cognition and affect. Cognitive impairment (A), labile affect (C), and motor symptoms (D) are more characteristic of other psychotic disorders like schizophrenia.