Question

A client diagnosed with schizophrenia is experiencing anhedonia. Which nursing diagnosis addresses the client's problem

that this symptom may generate?

Answer 1

Correct Answers:

Risk for suicide

Rationale :

✅Anhedonia is the inability to experience pleasure or interest in activities once enjoyed, a key symptom often seen in schizophrenia.

✅This symptom can severely affect a client's motivation and outlook on life, increasing the risk of suicide.

✅Disturbed sensory perception relates to altered perceptions, such as hallucinations or delusions, and does not directly address anhedonia.

✅Impaired verbal communication is related to difficulty with communication but does not specifically address the emotional and motivational issues that anhedonia brings.

✅Self-care deficit refers to difficulty with activities of daily living, but it is not the most fitting diagnosis for the emotional and psychological effects of anhedonia.

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Answer 2

Correct Answers:

Check the body for lice

Rationale :

✅Checking the body for lice should be the first intervention to rule out a real physical condition before addressing the possibility of delusions.

✅It's important to ensure that an actual infestation isn't the cause of the client's complaint.

✅Presenting reality regarding somatic delusions comes after verifying there is no actual infestation.

✅Advise for in-patient hospitalization for psychosis should be considered if the delusions are severe, but first, you need to ensure the client is not experiencing a physical issue.

✅Explaining the origin of persecutory delusions would be important but should be done after checking for physical conditions.

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Answer 3

Correct Answers:

Benztropine (Cogentin)

Rationale :

🎀Benztropine (Cogentin) is an anticholinergic medication used to treat extrapyramidal symptoms (EPS), such as restlessness (akathisia), which can be caused by antipsychotic medications like haloperidol.

🎀Fluphenazine decanoate (Prolixin Decanoate) is another antipsychotic, but it is unlikely to help with the restlessness caused by haloperidol.

🎀Clozapine (Clozaril) and Olanzapine (Zyprexa) are atypical antipsychotics that could be considered for treatment, but they do not address the immediate symptom of restlessness caused by haloperidol.

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Answer 4

Correct Answers:

Notify the client's physician, document the incident, and review elopement precautions

Rationale :

😊Notifying the physician is crucial for ensuring that appropriate clinical decisions are made regarding the client's care after elopement.

😊Documenting the incident is important for legal and professional reasons, as it provides a record of what happened.

😊Reviewing elopement precautions ensures that safety protocols are strengthened to prevent further incidents, and it helps in reassessing the patient's care plan.

😊Sending staff out to return the client could pose safety risks and is not a recommended course of action.

😊Staff should not be expected to leave the facility without proper planning and support.

😊Documenting that the client has been discharged is incorrect because the client has not voluntarily discharged themselves.

😊 The client remains under involuntary commitment.

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Answer 5

Correct Answers:

Maintain contact with the client and assure the client that seclusion is a way to maintain safety

Rationale :

🎀Maintaining contact with the client is essential in seclusion to ensure that the client feels safe and supported.

🎀It also helps in monitoring the client's behavior and emotional state.

🎀Assuring the client that seclusion is for safety is important to help the client understand why the measure is being taken and reduce feelings of isolation or punishment.

🎀Having no contact with the client would increase feelings of abandonment and may escalate distress or aggression.

🎀Teaching relaxation techniques and providing privacy are important, but the priority in this situation is to ensure safety and provide reassurance while the client is in seclusion.

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Answer 6

Correct Answers:

The client has been displaying signs and symptoms for 6 months

Rationale :

😉Schizophrenia is diagnosed when symptoms have been present for at least 6 months, including hallucinations, delusions, or disorganized thinking.

😉A developmental disorder such as autism is not specific to schizophrenia.

😉Medical conditions or substance abuse may cause similar symptoms but do not definitively indicate schizophrenia.

😉The duration of symptoms is crucial in the diagnosis of schizophrenia, and 6 months is a diagnostic marker.

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Answer 7

Correct Answers:

Hearing voices saying, "Go kill yourself."

Rationale :

🎗️Command hallucinations involve hearing voices giving commands, especially harmful ones, such as suicidal commands.

🎗️Seeing hallucinations of angels or similar figures is more likely visual hallucinations, not command hallucinations.

🎗️A combination of auditory, visual, and tactile hallucinations may indicate complex hallucinations, but the key here is command-type auditory hallucinations.

🎗️Thinking a stick is a snake is a form of visual misperception, not auditory hallucination.

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Answer 8

Correct Answers:

"Discontinue clozapine

Rationale :

💙Clozapine can cause severe neutropenia, as seen with the client's low WBC and ANC values.

💙The client’s WBC of 2000/mcL and ANC of 1000/μL are critically low, indicating a high risk of infection.

💙Benztropine (Cogentin) is for extrapyramidal symptoms, not for clozapine-induced problems.

💙The discontinuation of clozapine is necessary to prevent further complications like infection or agranulocytosis.

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Answer 9

Correct Answers:

Making observations

Rationale :

🎯Making observations involves identifying and commenting on the client's current behavior or mood, as the nurse did by acknowledging the client's restlessness.

🎯Clarifying is asking for more information or confirming details, which does not apply here.

🎯A broad opening statement is a general question that encourages conversation but isn't the specific technique here.

🎯Defending would involve protecting someone or something, which is not relevant to observing and addressing the client's behavior.

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Answer 10

Correct Answers:

Inappropriate affect

Rationale :

🔷Inappropriate affect refers to a mood expression that is not congruent with the situation, like smiling when discussing something tragic (such as the death of a pet).

🔷Restricted affect is a narrow range of emotional expression, not necessarily inappropriate.

🔷Broad affect involves a wide range of emotions, typically appropriate to the situation.

🔷Blunted affect is a diminished emotional response, rather than being inappropriate.

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Exam 1 Mental Health Nursing

No.

1 :
A client diagnosed with schizophrenia is experiencing anhedonia. Which nursing diagnosis addresses the client's problem
that this symptom may generate?

2 :
A client diagnosed with schizophrenia is seen in the mental health clinic complaining of insects infesting arms and legs. Which intervention should the nurse implement first?

3 :
A client has a history of schizophrenia, controlled by haloperidol (Haldol). During an assessment, the nurse notes continuous restlessness. Which medication would the nurse expect the physician to prescribe for this client?

4 :
A client has been involuntarily committed to a psychiatric unit. During the delivery of the evening dinner trays, the client escapes from the unit and the hospital. Which nursing intervention is appropriate in this situation?

5 :
A client has been placed in seclusion because the client has been deemed a danger to others. Which is the priority nursing intervention for this client on seclusion?

6 :
A client is brought to the emergency department after being found wandering the streets and talking to unseen others. Which situation is further evidence of a diagnosis of schizophrenia for this client?

7 :
A client is hearing command hallucinations. Which of the following may the client be experiencing?

8 :
A client is prescribed clozapine (Clozaril) 35 mg qd. Lab results reveal: RBC 4.7 million/mcL, Hct 48%, WBC 2000/mcL, and ANC 1000/μL. Which would the nurse expect the physician to order?

9 :
A client is restless. His face is flushed and he makes sarcastic remarks to other clients. The nurse responds by saying, "You look angry.” The nurse is using which communication technique?

10 :
A client is smiling while talking about the recent death of his/her pet. The nurse understands that the client is exhibiting:

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Exam 1 Mental Health Nursing

No.

1 : A client diagnosed with schizophrenia is experiencing anhedonia. Which nursing diagnosis addresses the client's problemthat this symptom may generate?

2 : A client diagnosed with schizophrenia is seen in the mental health clinic complaining of insects infesting arms and legs. Which intervention should the nurse implement first?

3 : A client has a history of schizophrenia, controlled by haloperidol (Haldol). During an assessment, the nurse notes continuous restlessness. Which medication would the nurse expect the physician to prescribe for this client?

4 : A client has been involuntarily committed to a psychiatric unit. During the delivery of the evening dinner trays, the client escapes from the unit and the hospital. Which nursing intervention is appropriate in this situation?

5 : A client has been placed in seclusion because the client has been deemed a danger to others. Which is the priority nursing intervention for this client on seclusion?

6 : A client is brought to the emergency department after being found wandering the streets and talking to unseen others. Which situation is further evidence of a diagnosis of schizophrenia for this client?

7 : A client is hearing command hallucinations. Which of the following may the client be experiencing?

8 : A client is prescribed clozapine (Clozaril) 35 mg qd. Lab results reveal: RBC 4.7 million/mcL, Hct 48%, WBC 2000/mcL, and ANC 1000/μL. Which would the nurse expect the physician to order?

9 : A client is restless. His face is flushed and he makes sarcastic remarks to other clients. The nurse responds by saying, "You look angry.” The nurse is using which communication technique?

10 : A client is smiling while talking about the recent death of his/her pet. The nurse understands that the client is exhibiting:

1 :
A client diagnosed with schizophrenia is experiencing anhedonia. Which nursing diagnosis addresses the client's problem
that this symptom may generate?

2 :
A client diagnosed with schizophrenia is seen in the mental health clinic complaining of insects infesting arms and legs. Which intervention should the nurse implement first?

3 :
A client has a history of schizophrenia, controlled by haloperidol (Haldol). During an assessment, the nurse notes continuous restlessness. Which medication would the nurse expect the physician to prescribe for this client?

4 :
A client has been involuntarily committed to a psychiatric unit. During the delivery of the evening dinner trays, the client escapes from the unit and the hospital. Which nursing intervention is appropriate in this situation?

5 :
A client has been placed in seclusion because the client has been deemed a danger to others. Which is the priority nursing intervention for this client on seclusion?

6 :
A client is brought to the emergency department after being found wandering the streets and talking to unseen others. Which situation is further evidence of a diagnosis of schizophrenia for this client?

7 :
A client is hearing command hallucinations. Which of the following may the client be experiencing?

8 :
A client is prescribed clozapine (Clozaril) 35 mg qd. Lab results reveal: RBC 4.7 million/mcL, Hct 48%, WBC 2000/mcL, and ANC 1000/μL. Which would the nurse expect the physician to order?

9 :
A client is restless. His face is flushed and he makes sarcastic remarks to other clients. The nurse responds by saying, "You look angry.” The nurse is using which communication technique?

10 :
A client is smiling while talking about the recent death of his/her pet. The nurse understands that the client is exhibiting: