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The nurse is working with a client with schizophrenia, disorganized type. It is time for the client to get up and eat breakfast. Which of the following statements by the nurse would be most effective in helping the client prepare for breakfast?
- A. I'll expect you in the dining room in 20 minutes.
- B. It's time to put your dress on now.
- C. Stay right there and I'll get your clothes for you.
- D. Why don't you stay here and I'll get your tray for you.
Correct Answer: B
Rationale: Clear, simple directions like dressing support self-care in disorganized schizophrenia, unlike authoritarian demands or doing tasks for the client.
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During the nursing assessment, a client describes constantly hearing voices mumbling in the background. The client denies that the voices are telling him to do anything harmful. The nurse documents that the client is experiencing which of the following?
- A. Command hallucinations
- B. Auditory hallucinations
- C. Olfactory hallucinations
- D. Gustatory hallucinations
Correct Answer: B
Rationale: Hearing non-command voices indicates auditory hallucinations, the most common type in schizophrenia, distinct from command, olfactory, or gustatory hallucinations.
A client with schizophrenia is seen sitting alone and talking out loud. Suddenly, the client stops and turns as if listening to someone. The nurse approaches and sits down beside the client. Which of the following is the best initial response by the nurse?
- A. I can see you want to be alone. I'll come back another time.
- B. What are you hearing and seeing?
- C. I don't hear or see anyone else, what are you hearing and seeing?
- D. I can tell you are hearing voices but they are not real.
Correct Answer: C
Rationale: Asking what the client is experiencing while presenting reality validates their perception and encourages discussion, unlike dismissing, assuming, or denying the experience.
Which of the following questions would best help the nurse to evaluate the effectiveness of antipsychotic medications for a client who has schizophrenia?
- A. Have the symptoms you were experiencing disappeared?
- B. If the symptoms have not disappeared, are you able to carry out your daily life despite the persistence of some psychotic symptoms?
- C. Are you committed to taking the medication as prescribed?
- D. Are you satisfied with your quality of life?
- E. Do you have access to community agencies that will help you to live successfully in this community?
Correct Answer: A,B,C,D
Rationale: Questions about symptom reduction, daily functioning, adherence, and quality of life directly evaluate medication effectiveness, unlike community agency access.
The parents of a young adult male who has schizophrenia ask how they can recognize when their son is beginning to relapse. The nurse teaches the family to look for which of the following?
- A. Excessive sleeping
- B. Fatigue
- C. Irritability
- D. Increased inhibition
- E. Negativity
Correct Answer: B,C,E
Rationale: Fatigue, irritability, and negativity are early relapse signs, unlike excessive sleeping or increased inhibition, which are less specific to schizophrenia relapse.
All of the following are nursing diagnoses identified for a client with schizophrenia. The student nurse correctly anticipates which diagnosis will resolve when the client's negative symptoms improve?
- A. Impaired verbal communication
- B. Risk for other-directed violence
- C. Disturbed thought processes
- D. Social isolation
Correct Answer: D
Rationale: Social isolation, a negative symptom, improves with negative symptom reduction, unlike impaired communication, violence risk, or thought processes, which are positive symptom-related.