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
Assessment of a client with schizophrenia reveals that he is hearing voices that tell him that people are staring at him and illusions. When developing the plan of care for this client, which nursing diagnosis would be most appropriate?
Correct Answer: C
Rationale: Disturbed sensory perception (
C) is most appropriate, as the client?s hallucinations (voices) and illusions directly indicate altered sensory processing. Disturbed thought processes (
A) is less specific, risk for violence (
B) is not indicated, and ineffective coping (
D) is secondary.
Question 2 of 5
A nursing instructor is preparing a class lecture about schizophrenia and outcomes focusing on recovery. Which of the following would the instructor include as a major goal?
Correct Answer: D
Rationale: Social engagement (
D) is a major recovery goal in schizophrenia, promoting reintegration and quality of life. Continuity of care (
A) and crisis stabilization (
C) are means to achieve recovery, and shorter stays (
B) are logistical, not primary goals.
Question 3 of 5
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.
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.
Question 4 of 5
A client who has a major depressive episode tells the nurse that for the past 2 weeks, he has been hearing voices and at times thinks that someone is following him. History reveals that he had these alternating symptoms before along with times when he has experienced neither of these symptoms and has been able to function adequately. The nurse interprets these findings as suggesting which of the following?
Correct Answer: D
Rationale: Schizoaffective disorder (
D) combines mood episodes (depression) with psychotic symptoms (hallucinations, paranoia) that persist but allow periods of adequate functioning, matching the client?s history. Paranoid (
A) and undifferentiated schizophrenia (
B) lack prominent mood components, and brief psychotic disorder (
C) is shorter in duration.
Question 5 of 5
A nursing instructor is developing a class lecture that compares and contrasts schizoaffective disorder with schizophrenia. When describing one of the differences between these two diagnoses, which of the following would the instructor include as reflecting schizoaffective disorder?
Correct Answer: A
Rationale: Schizoaffective disorder (
A) is characterized by episodic mood disturbances (depressive or manic) alongside psychotic symptoms, unlike the more persistent psychotic symptoms in schizophrenia. Self-care difficulties (
B) and hallucination severity (
C) are not distinguishing features, and suicide risk (
D) is not necessarily lower.