Nokea
The client with schizophrenia makes the following statement. 'I just don't know how to count. The sky turned to fire. I have a ball in my head.' The nurse documents this entire statement as an example of
- A. Flight of ideas
- B. Ideas of reference
- C. Delusional thinking
- D. Associative looseness
Correct Answer: D
Rationale: The fragmented, poorly related thoughts demonstrate associative looseness, not flight of ideas (rapid but connected thoughts), ideas of reference, or solely delusional thinking.
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When performing discharge planning for a client who has schizophrenia, the nurse anticipates barriers to adhering to the medication regimen. The nurse assesses which of the following as improving the likelihood that the client will follow the prescribed medication regimen?
- A. Short-term memory intact
- B. History of missing appointments
- C. Receives monthly disability checks
- D. Walking is primary mode of transportation
- E. States location of pharmacy nearest his residence
Correct Answer: A,C,E
Rationale: Intact short-term memory, financial resources, and knowing the pharmacy location enhance medication adherence, unlike appointment history or transportation barriers.
A college freshman is admitted to the hospital with a diagnosis of schizophrenia. Friends reported that she had been in her room for 2 days in a trance-like state, not eating nor speaking to anyone. Which of the following is the highest priority for this client?
- A. Assessing fluid intake and output
- B. Completing an assessment of mental status
- C. Obtaining more data about her college experiences
- D. Providing for adequate rest
Correct Answer: A
Rationale: Assessing fluid intake and output prioritizes physiologic homeostasis, critical for a client not eating, over mental status, rest, or background data.
The nurse is preparing a client with schizophrenia for discharge. The nurse asks the client, 'How are you going to care for yourself at home?' The purpose of the nurse's question is to assess the client's
- A. Self concept
- B. Judgment
- C. Insight
- D. Social support system
Correct Answer: C
Rationale: Asking about self-care plans assesses insight, the client's awareness of their illness and ability to manage it, unlike self-concept, judgment, or social support.
A client with schizophrenia is reluctant to take his prescribed oral medication. The most therapeutic response by the nurse to this refusal is,
- A. I can see that you're uncomfortable now, so we can wait until tomorrow.
- B. If you refuse these pills, you'll have to get an injection.
- C. What is it about the medicine that you don't like?
- D. You know you have to take this medicine for your own good.
Correct Answer: C
Rationale: Exploring reasons for medication refusal addresses barriers to compliance, fostering collaboration, unlike threats, delays, or non-therapeutic insistence.
The client with schizophrenia tells the nurse that rats have started to eat his brain. The best response by the nurse would be.
- A. Have you discussed this with your physician?
- B. How could that be possible?
- C. You cannot have rats in your brain.
- D. You look OK to me.
Correct Answer: A
Rationale: Referring to the physician for a new symptom like a delusion prompts potential medication review, unlike defensive, dismissive, or non-therapeutic responses.