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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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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.
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.
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 client with schizoaffective disorder is prescribed clozapine to treat her symptoms. Which of the following instructions would the nurse provide?
- A. Keep a record of how often and how long you experience the side effect of dry mouth.
- B. Monitor your urinary output and notify your doctor if your urine changes color.
- C. Keep an eye on your weight, and if you gain weight rapidly, notify your doctor.
- D. If you experience any drowsiness, discontinue taking this medication.
Correct Answer: C
Rationale: Clozapine (C) is associated with significant weight gain, a metabolic side effect requiring monitoring and reporting if rapid. Dry mouth (A) is minor, urine color changes (B) are not typical, and discontinuing for drowsiness (D) is incorrect without medical guidance.
A nurse is developing a teaching plan for a client with schizophrenia. Which method would the nurse use to be most effective?
- A. Engaging the client in trial and error learning
- B. Having the client write down information after directly being given the correct information
- C. Asking the client questions that encourage the client to guess at the correct answer
- D. Using visual aids that are very colorful and full of descriptive graphic images
Correct Answer: B
Rationale: Having the client write down information (B) reinforces learning through repetition and active engagement, accommodating cognitive deficits in schizophrenia. Trial and error (A) or guessing (C) may confuse, and colorful visuals (D) may overstimulate psychotic clients.