ATI LPN
Test Bank for Psychiatric Nursing: Contemporary Practice
Chapter 22 : Schizophrenia and Related Disorders: Nursing Care of Persons with Thought Disorders Questions
Question 1 of 5
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?
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.
Question 2 of 5
The nurse is caring for an elderly client who has been taking an antipsychotic medication for 1 week. The nurse notifies the physician when he observes that the client has muscle rigidity that resembles Parkinson?s disease. Which agent would the nurse expect the physician to prescribe?
Correct Answer: A
Rationale: Anticholinergic agents (
A), such as benztropine, are used to treat extrapyramidal symptoms (EPS) like parkinsonian muscle rigidity caused by antipsychotics, by balancing acetylcholine and dopamine. Anxiolytics (
B) and benzodiazepines (
C) address anxiety, not EPS, and beta-blockers (
D) treat akathisia or other symptoms, not rigidity.
Question 3 of 5
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?
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.
Question 4 of 5
A hospitalized client with schizophrenia is receiving antipsychotic medications. While assessing the client, the nurse identifies signs and symptoms of a dystonic reaction. Which agent would the nurse expect to administer?
Correct Answer: A
Rationale: Diphenhydramine (
A), an antihistamine with anticholinergic properties, is commonly used to treat acute dystonic reactions caused by antipsychotics, relieving muscle spasms. Propranolol (
B) treats akathisia, while risperidone (
C) and aripiprazole (
D) are antipsychotics that could worsen dystonia.
Question 5 of 5
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?
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.