Nokea
The nurse is assessing a newly admitted client diagnosed with schizoaffective disorder. The nurse assesses the client?s level of anxiety and reactions to stressful situations, obtaining this information for which reason?
- A. To help determine the client?s outcomes after treatment
- B. To help identify whether or not the client?s mental competency is intact
- C. To act as a predictor of the client?s risk for a suicide attempt
- D. To provide a basis for evaluating the client?s social skills
Correct Answer: C
Rationale: Assessing anxiety and stress reactions (C) in schizoaffective disorder helps predict suicide risk, as heightened anxiety can exacerbate mood and psychotic symptoms. Outcomes (A), competency (B), and social skills (D) are less directly tied to this assessment.
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When assessing a client for possible disordered water balance, the nurse checks the client?s urine specific gravity. Which result would lead the nurse to suspect that the client is experiencing severe disordered water balance?
- A. 1.02
- B. 1.011
- C. 1.005
- D. 1.002
Correct Answer: D
Rationale: A urine specific gravity of 1.002 (D) is extremely low, indicating overly dilute urine, consistent with severe disordered water balance (e.g., psychogenic polydipsia). Normal range is 1.010?1.030, so 1.020 (A) and 1.011 (B) are closer to normal, and 1.005 (C) is less severe.
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.
The nurse is caring for a client who was diagnosed with schizoaffective disorder. Based on the nurse?s understanding of this disorder, the nurse develops a plan of care to address which issue as the top priority?
- A. Suicide
- B. Aggression
- C. Substance abuse
- D. Eating disorder
Correct Answer: A
Rationale: Suicide (A) is the top priority in schizoaffective disorder due to the combined risk of mood disturbances (e.g., depression) and psychosis, both of which elevate suicide risk. Aggression (B), substance abuse (C), and eating disorders (D) are concerns but less immediate unless actively present.
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.
A client is being released from the inpatient psychiatric unit with a diagnosis of schizophrenia and treatment with antipsychotic medications. After teaching the client and family about managing the disorder, the nurse determines that the teaching was effective when they state which of the following should be reported immediately?
- A. Elevated temperature
- B. Tremor
- C. Decreased blood pressure
- D. Weight gain
Correct Answer: A
Rationale: Elevated temperature (A) could indicate a serious side effect like neuroleptic malignant syndrome or infection (e.g., agranulocytosis with clozapine), requiring immediate reporting. Tremor (B), decreased blood pressure (C), and weight gain (D) are less urgent, though they warrant monitoring.