Nokea
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.
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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.
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.
The nurse is preparing to document information obtained from a client diagnosed with a delusional disorder who is experiencing somatic delusions. Which of the following would the nurse most likely document?
- A. Disorientation
- B. Reduced attention span
- C. Above average intelligence
- D. Body complaints
Correct Answer: D
Rationale: Somatic delusions in delusional disorder involve persistent beliefs about bodily functions or sensations (D), such as unusual odors or physical defects. Disorientation (A), reduced attention (B), and above-average intelligence (C) are not typically associated with somatic delusions.
After assessing a client with schizophrenia, the nurse suspects that the client is experiencing an anticholinergic crisis. Which of the following would the nurse most likely have assessed? Select all that apply.
- A. Dilated reactive pupils
- B. Blurred vision
- C. Ataxia
- D. Coherent speech
- E. Facial pallor
- F. Disorientation
Correct Answer: B,C,F
Rationale: Anticholinergic crisis symptoms include blurred vision (B), ataxia (C), and disorientation (F) due to excessive anticholinergic effects (e.g., from medications). Dilated pupils (A) may occur but are less specific, coherent speech (D) is unlikely, and facial pallor (E) is not typical.
The nurse is caring for a client who has been receiving treatment for schizophrenia with chlorpromazine for the past year. It would be essential for the nurse to monitor the client for which of the following?
- A. Weight loss
- B. Torticollis
- C. Hypoglycemia
- D. Tardive dyskinesia
Correct Answer: D
Rationale: Tardive dyskinesia (D), a potentially irreversible side effect of long-term use of typical antipsychotics like chlorpromazine, involves involuntary movements and requires ongoing monitoring. Weight loss (A) is unlikely (weight gain is more common), torticollis (B) is an acute dystonia, and hypoglycemia (C) is not a typical side effect.