Nokea
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.
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The nurse is caring for a hospitalized client who has schizophrenia. The client has been taking antipsychotic medications for 1 week when the nurse observes that the client?s eyes are fixed on the ceiling. The nurse interprets this finding as which of the following?
- A. Akathisia
- B. Oculogyric crisis
- C. Retrocollis
- D. Tardive dyskinesia
Correct Answer: B
Rationale: Oculogyric crisis (B) is an acute dystonic reaction characterized by fixed upward gaze, often caused by antipsychotics within days of starting treatment. Akathisia (A) involves restlessness, retrocollis (C) is neck muscle dystonia, and tardive dyskinesia (D) involves late-onset involuntary movements, none of which match the symptom.
The nurse is caring for a client who was just admitted with a diagnosis of schizoaffective disorder with depression. Which agent would the nurse anticipate as being prescribed for this client?
- A. Lithium
- B. Haloperidol
- C. Chlorpromazine
- D. Clozapine
Correct Answer: D
Rationale: Clozapine (D) is effective for schizoaffective disorder, addressing both psychotic and mood symptoms, especially in treatment-resistant cases. Lithium (A) is primarily for bipolar disorder, and haloperidol (B) and chlorpromazine (C) are less effective for mood components.
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 client has been diagnosed with schizophrenia. Assessment reveals that the client lives alone. His clothing is disheveled, his hair is uncombed and matted, and his body has a strange odor. During an interview, the client?s family voices a desire for the client to live with them when he is discharged. Based on the assessment findings, which nursing diagnosis would be the priority?
- A. Ineffective Role Performance related to symptoms of schizophrenia.
- B. Social Isolation related to auditory hallucinations.
- C. Dysfunctional Family Processes related to psychosis.
- D. Bathing Self-Care Deficit related to symptoms of schizophrenia.
Correct Answer: D
Rationale: Bathing Self-Care Deficit (D) is the priority nursing diagnosis, as the client?s disheveled appearance, matted hair, and body odor indicate an immediate inability to maintain personal hygiene, which affects health and social integration. Ineffective Role Performance (A) and Social Isolation (B) are relevant but secondary, and Dysfunctional Family Processes (C) is not supported by the family?s supportive stance.