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The client with schizophrenia is experiencing delusions. Which of the following is the most appropriate response by the nurse?
- A. I can see you want to be alone. I'll come back another time.
- B. What are you hearing and seeing?
- C. I don't hear or see anyone else, what are you hearing and seeing?
- D. I can tell you are hearing voices but they are not real.
Correct Answer: C
Rationale: Presenting reality while inquiring about the client's experience avoids reinforcing delusions and promotes engagement, unlike dismissing or confronting the delusion directly.
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The parents of a young adult male who has schizophrenia ask how they can recognize when their son is beginning to relapse. The nurse teaches the family to look for which of the following?
- A. Excessive sleeping
- B. Fatigue
- C. Irritability
- D. Increased inhibition
- E. Negativity
Correct Answer: B,C,E
Rationale: Fatigue, irritability, and negativity are early relapse signs, unlike excessive sleeping or increased inhibition, which are less specific to schizophrenia relapse.
A client with schizophrenia is admitted to the inpatient unit. He does not speak when spoken to but has been observed talking to himself on occasion. What would be the priority objective at this time?
- A. The client will begin talking with other clients
- B. The client will express his feelings freely
- C. The client will increase his socialization with others
- D. The client will increase his reality orientation
Correct Answer: D
Rationale: Increasing reality orientation is the priority to ground the client before addressing socialization or emotional expression, given his current withdrawn state.
The nurse is assessing for negative symptoms of schizophrenia in a newly admitted client. The nurse would note which behavior as indicative of a negative symptom?
- A. Difficulty staying on subject when responding to assessment questions
- B. Belief of owning a transportation device allowing for travel to the center of the Earth
- C. Hesitant to answer the nurse's questions during the assessment interview
- D. Mimicking the postural changes made by the nurse during the assessment interview
Correct Answer: C
Rationale: Hesitancy to answer reflects alogia, a negative symptom, unlike associative looseness, delusions, or echopraxia, which are positive symptoms of schizophrenia.
During the nursing assessment, a client describes constantly hearing voices mumbling in the background. The client denies that the voices are telling him to do anything harmful. The nurse documents that the client is experiencing which of the following?
- A. Command hallucinations
- B. Auditory hallucinations
- C. Olfactory hallucinations
- D. Gustatory hallucinations
Correct Answer: B
Rationale: Hearing non-command voices indicates auditory hallucinations, the most common type in schizophrenia, distinct from command, olfactory, or gustatory hallucinations.
A client who has suspicion has been placed in a room with a roommate. The night nurse reports that this client has been awake for the past 3 nights. The likely explanation for his wakefulness is which of the following?
- A. He is fearful of what his roommate might do to him while he sleeps.
- B. He is a light sleeper and unaccustomed to a roommate.
- C. He is watching for an opportunity to escape.
- D. He is worrying about his family problems.
Correct Answer: A
Rationale: Suspicion in schizophrenia often causes fear of harm from others, like a roommate, making it the most likely reason for wakefulness over other explanations.