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Assessment of a client with schizophrenia reveals that he is hearing voices that tell him that people are staring at him and illusions. When developing the plan of care for this client, which nursing diagnosis would be most appropriate?
- A. Disturbed thought processes
- B. Risk for self-directed violence
- C. Disturbed sensory perception
- D. Ineffective coping
Correct Answer: C
Rationale: Disturbed sensory perception (C) is most appropriate, as the client?s hallucinations (voices) and illusions directly indicate altered sensory processing. Disturbed thought processes (A) is less specific, risk for violence (B) is not indicated, and ineffective coping (D) is secondary.
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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 client has been diagnosed with schizophrenia. Assessment reveals that the client lives alone. His clothing is disheveled, his hair is uncombed and matted, and his body has a strange odor. During an interview, the client?s family voices a desire for the client to live with them when he is discharged. Based on the assessment findings, which nursing diagnosis would be the priority?
- A. Ineffective Role Performance related to symptoms of schizophrenia.
- B. Social Isolation related to auditory hallucinations.
- C. Dysfunctional Family Processes related to psychosis.
- D. Bathing Self-Care Deficit related to symptoms of schizophrenia.
Correct Answer: D
Rationale: Bathing Self-Care Deficit (D) is the priority nursing diagnosis, as the client?s disheveled appearance, matted hair, and body odor indicate an immediate inability to maintain personal hygiene, which affects health and social integration. Ineffective Role Performance (A) and Social Isolation (B) are relevant but secondary, and Dysfunctional Family Processes (C) is not supported by the family?s supportive stance.
The nurse is preparing to document information obtained from a client diagnosed with a delusional disorder who is experiencing somatic delusions. Which of the following would the nurse most likely document?
- A. Disorientation
- B. Reduced attention span
- C. Above average intelligence
- D. Body complaints
Correct Answer: D
Rationale: Somatic delusions in delusional disorder involve persistent beliefs about bodily functions or sensations (D), such as unusual odors or physical defects. Disorientation (A), reduced attention (B), and above-average intelligence (C) are not typically associated with somatic delusions.
A nurse is providing care to a client just recently diagnosed with schizophrenia during an inpatient hospital stay. Throughout the day, the nurse observes the client drinking from the water fountain quite frequently as well as carrying cans of soda and bottles of water with him wherever he goes. Upon entering the client?s room, the nurse sees numerous empty cups that had been filled with fluids on his table and in the trash can. The room has an odor of urine. The nurse suspects which of the following?
- A. Diabetes mellitus
- B. Disordered water balance
- C. Tardive dyskinesia
- D. Orthostatic hypotension
Correct Answer: B
Rationale: Excessive fluid intake and urine odor suggest disordered water balance (B), such as psychogenic polydipsia, common in schizophrenia, leading to excessive drinking and urination. Diabetes mellitus (A) may cause thirst but not typically urine odor in this context. Tardive dyskinesia (C) and orthostatic hypotension (D) are unrelated to these symptoms.
A nurse is working with a group of clients diagnosed with schizophrenia in a community setting. Which of the following would least likely be a priority?
- A. Improving the quality of life
- B. Instilling hope
- C. Managing psychosis
- D. Preventing relapse
Correct Answer: A
Rationale: While improving quality of life (A) is important, managing psychosis (C), preventing relapse (D), and instilling hope (B) are more immediate priorities in schizophrenia care to stabilize symptoms and maintain recovery. Quality of life is a longer-term goal.