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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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The nurse is caring for a client diagnosed with a delusional disorder. While assessing this client, which of the following would the nurse expect to find?
- A. History of chronic major depression
- B. Consistently disrupting behavior patterns
- C. Verbalization of bizarre delusions
- D. Living with one or more delusions for a period of time
Correct Answer: D
Rationale: Delusional disorder (D) is characterized by persistent, non-bizarre delusions lasting at least one month without prominent mood or psychotic symptoms. Depression (A) is not typical, disruptive behavior (B) is uncommon, and delusions are not bizarre (C) but plausible.
A group of nursing students is reviewing the various theories related to the etiology of schizophrenia. The students demonstrate understanding of the information when they identify which neurotransmitter as being responsible for hallucinations and delusions?
- A. Dopamine
- B. Serotonin
- C. Norepinephrine
- D. Gamma-amino butyric acid (GABA)
Correct Answer: A
Rationale: Dopamine (A) dysregulation, particularly excess in certain brain regions, is strongly linked to hallucinations and delusions in schizophrenia. Serotonin (B), norepinephrine (C), and GABA (D) play roles in other disorders or symptoms but are less directly associated with these psychotic features.
A client hospitalized for treatment of schizophrenia has been receiving olanzapine (Zyprexa) for the past 2 months. The nurse would be especially alert for which of the following?
- A. Weight loss
- B. Hypertension
- C. Diarrhea
- D. Diabetes
Correct Answer: D
Rationale: Olanzapine (D) is associated with metabolic side effects, including an increased risk of diabetes due to weight gain and insulin resistance. Weight loss (A) is unlikely, hypertension (B) is less common, and diarrhea (C) is not a primary concern with olanzapine.
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.
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.