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One evening, a client with schizophrenia leaves his room and begins marching in the hall. When approached by the nurse, the client says, 'Goodays I'm supposed to guard the area.' Which of the following responses would be best?
- A. I understand you hear a voice. You and I are the only ones in the hall, and I don't hear a voice.
- B. The voices are part of your illness, and they will leave in time.
- C. This guarding responsibility can make you tired. You rest for now, and I'll guard a while.
- D. You are just imagining these things. Do not pay any attention to the voices.
Correct Answer: A
Rationale: Acknowledging the client's experience while presenting reality validates their perception without reinforcing the delusion, unlike dismissive or reinforcing responses.
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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 who has schizophrenia is having a conversation with the nurse suddenly stops talking in the middle of a sentence. The client is experiencing which type of thought disruption?
- A. Thought withdrawal
- B. Thought insertion
- C. Thought blocking
- D. Thought broadcasting
Correct Answer: C
Rationale: Sudden cessation of speech indicates thought blocking, unlike thought withdrawal (belief others take thoughts), insertion (belief others place thoughts), or broadcasting (belief others hear thoughts).
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.
A client asks the nurse upon discharge, 'What should I do if I forget to take my medicine?' The nurse should explain to the client which of the following?
- A. Just double the dose next time it is scheduled.
- B. Skip that dose and resume your regular with the next dose.
- C. Don't miss doses, or you will not maintain therapeutic drug levels.
- D. If you remember within 3 to 4 hours later than it is due, take it then. If you remember more than 4 hours after it was due, do not take that dose.
Correct Answer: D
Rationale: Taking a missed dose within 3-4 hours maintains therapeutic levels, but skipping it if later avoids disruption, unlike doubling doses or vague warnings.