ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 72 : Caring for Clients With Dementia and Thought Disorders Questions
Question 1 of 5
The nurse is caring for a client who has experienced readmission to the behavioral health unit for an exacerbation of schizophrenia. Which assessment question asked by the nurse identifies a possible cause for the return?
Correct Answer: B
Rationale: The nurse is correct to identify that noncompliance with drug therapy is the leading cause of the return of disease symptoms and the need for short-term hospitalization. Asking when the client's last dose of medication was opens communication for when the medication was last administered. If it was not at the prescribed time, the conversation allows the nurse to probe why. Taking a generic medication does not change the effectiveness. Asking if the client can afford the medication or if the medication causes side effects does not directly address the question of noncompliance.
Question 2 of 5
During a multidisciplinary meeting, the group discussed potential signs of tardive dyskinesia noted sporadically in a client. Following the meeting, symptoms progressed for the client. Which medical order does the nurse anticipate?
Correct Answer: B
Rationale: Nurses and the multidisciplinary team consistently assess the client taking antipsychotic medications to check for tardive dyskinesia. When symptoms progress, the nurse should report the symptoms immediately because the drug must be discontinued. Reducing the dose, adjunct medications, and alternative treatments would not be the medical orders issued.
Question 3 of 5
The nurse is observing the interaction between a parent and child with schizophrenia. The child states, 'The man visiting me said you went on vacation without me.' The parent replies 'There is no man, you are just making that up.' When interacting with the parent privately, which reply from the parent would the nurse suggest?
Correct Answer: A
Rationale: The nurse is correct to suggest not arguing with the client. This can escalate the situation. The nurse should suggest not validating the delusional belief and focus the discussion to the 'here and now.'
Question 4 of 5
Which nursing action is most helpful in managing the positive symptoms of schizophrenia?
Correct Answer: C
Rationale: Positive symptoms of schizophrenia include delusions, hallucinations, and fluent but disorganized speech. Positive symptoms are managed by medication administration. Therapeutic communication, physical activity, and drawing are excellent ways to express emotions.
Question 5 of 5
The nurse is instructing the parents of a 21-year-old with schizophrenia who hears voices. Which response by the parent to the child validates that the parent understands the discharge teaching?
Correct Answer: D
Rationale: The parent is most correct to state not hearing the voices but then asking the client to share what the voices are saying. By identifying the content of the hallucinations, the parent can determine the safety of the client or if others are in jeopardy. Also, the parent is correct to call the auditory hallucinations by the term 'the voices.'