Which symptom would the nurse assess in a patient with posttraumatic stress disorder?

What assessment finding would suggest to the nurse that the client with posttraumatic stress disorder (PTSD) is experiencing dissociation?

The client is often "staring into space" and has no idea how much time has passed

"Spacing out" is an example of dissociation (depersonalization). It is not uncommon for the client with PTSD to experience failure of coping skills, sleep disturbances, and reluctance to acknowledge moods, but these are not evidences of dissociation.

A client was physically assaulted 1 week ago. While interviewing the client, the client reports having trouble remembering the event and feeling as if the client is walking around in a dreamlike state. The psychiatric-mental health nurse interprets these findings as most likely associated with which condition?

Acute stress disorder

Acute stress disorder occurs within the first month of exposure to extreme trauma: combat, rape, physical assault, near-death experience, or witnessing a murder. Symptoms begin during or shortly after the event. The symptom of dissociation, a state of detachment in which people experience the world as dreamlike and unreal, is a primary feature. Poor memory of specific events surrounding the trauma also may accompany the dissociative state. When symptoms of acute stress disorder continue for more than 1 month and are accompanied by functional impairment or stress, the diagnosis changes to acute posttraumatic stress disorder.

A client has developed posttraumatic stress disorder (PTSD) after a violent sexual assault committed by a close family member. When planning this client's care, the nurse should follow what guideline?

The nurse should avoid touching the client during interactions unless necessary

A client with a diagnosis of posttraumatic stress disorder (PTSD) tells the nurse, "When things get really bad, it sometimes feels like I'm not even in my body, like I'm floating around and watching myself." How should the nurse best interpret this client's statement?

The client is likely experiencing derealization as a result of PTSD

The client's statement suggests derealization, which is an avoidance response to PTSD. This needs to be directly addressed but not necessarily in an inpatient setting. Assessment for suicide risk is necessary for all clients with PTSD, but the presence of derealization does not indicate an acute risk. Derealization is not a direct result of hyperarousal, though the two phenomena can certainly coexist.

A nurse works in a psychiatric clinic. During a counseling session, the nurse finds that the client who has posttraumatic stress disorder (PTSD) is unable to identify the intensity of the client's emotions. The client states that extreme emotions appear out of nowhere and with no warning. What suggestion should the nurse provide to help the client get in touch with the client's emotions?

"Use a journal or a log to write down your feelings."

Some clients with PTSD may find it difficult to gauge the intensity of their feelings. These clients can write about their feelings in a log or a journal. They can write about their feelings at specific intervals. This helps them to gauge the intensity of the feelings and also identify any triggers. Deep breathing and relaxation help reduce the intensity of the feelings, but they do not help in gauging them. Grounding techniques help to diminish or avoid episodes of dissociative symptoms, but they do not help in identifying the feelings and their intensity.

A client with posttraumatic stress disorder has been referred for cognitive processing therapy. What would be the predominant symptom in a client for whom this therapy would be useful?

Feelings of guilt and self-blame

Cognitive processing therapy focuses on erroneous beliefs that interfere with daily life, such as guilt and self-blame. It helps to change the incorrect beliefs and develop a feeling of self-worth. Cognitive processing therapy does not directly influence anger or irritable behavior in these clients. Cognitive processing therapy does not directly help clients to remember details related to the traumatic event. This also does not directly help clients overcome avoidance behavior. Exposure therapy and adaptive disclosure techniques are helpful in combating avoidance behavior related to the traumatic event.

The nurse is interviewing a client who has been diagnosed with posttraumatic stress disorder (PTSD) after being randomly attacked with a gun. The client describes a recent event where the client panicked and jumped for cover when a car backfired on the street. How should the nurse best interpret this event?

The client is experiencing hyperarousal

When lecturing about dissociative disorders to a group of nursing students, a nurse states that an essential feature of these disorders involves what?

Failure to integrate identity, memory, and consciousness

The essential feature of these disorders involves a failure to integrate identity, memory, and consciousness. That is, unwanted intrusive thoughts disrupt one's contact with the here and now, or memories that are normally accessible are lost. These disorders are closely related to trauma- and stressor-related disorders but are categorized separately.

The nurse is dialoguing with a client who has been referred after witnessing a workplace accident several weeks ago that resulted in a coworker's death. What assessment finding would support a diagnosis of posttraumatic stress disorder (PTSD)?

The client states that the client is often "awake for hours and hours each night."

A nurse observes that a client with posttraumatic stress disorder (PTSD) is experiencing dissociative symptoms. What instruction should the nurse give to the client to prevent being stuck in a daze?

"Look around the room."

The client is experiencing a dissociative episode. There is a high probability that the client will be stuck in a daze in this situation. The nurse should ask the client to look around the room so that the client moves the eyes and avoids being locked in a daze or flashback. Telling the client to sleep would not prevent the client from being stuck in a daze. The client is dissociating, thus it is inappropriate to ask the client to express feelings. Making the client sit with the nurse is not useful, as this would not decrease the dissociative symptoms. This instruction should be given especially when the client has tendencies toward self-harm and suicide.

The psychiatric mental health nurse is assessing a client who was diagnosed with posttraumatic stress disorder (PTSD) after the death of the client's child from a medical error. What assessment finding would most warrant interventions aimed at addressing the client's dissociation?

The client reports large gaps in memory of the traumatic event

Rationale: Amnesia about traumatic events is characteristic of dissociation. Emotional lability, apathy, and agitation are not unusual in a client dealing with PTSD, but these do not directly indicate the presence of dissociation.

A client with posttraumatic stress disorder tells the nurse, "I deserved to be abused that way. I feel I am the one responsible for that incident. I don't have any hopes in life. I no longer mean anything to anybody." Based on these statements, which is the most appropriate nursing diagnosis?

Chronic low self-esteem

On the basis of the client's statements, the client has developed extreme negative emotions regarding the individual self. The most appropriate diagnosis of the client in this situation would be chronic low self-esteem. The client does not seem to have any suicidal ideation. The client has not mentioned whether the problems are affecting daily life. Therefore, the nursing diagnosis is not ineffective coping. The client does not show any signs of self-harm.

A nurse is performing a follow-up assessment of a client who had been treated for posttraumatic stress disorder (PTSD) a year ago. The client tells the nurse that the client is not able to maintain relationships and that the relationships last for a very short time. What is the most likely reason for this problem?

The client has issues with developing trust.

A client with PTSD usually has difficulties in maintaining relationships. This occurs because the ability to build trust is severely impaired in them. Issues such as irritability, negativity, and having dissociative disorder would have already been treated if the client has had proper treatment.

The psychiatric mental health nurse is working with a client who has been diagnosed with posttraumatic stress disorder (PTSD). Assessment reveals that the client is experiencing frequent episodes of intrusion. The nurse should consequently prioritize what assessment?

Assessing the quantity and quality of the client's sleep

Intrusion almost always takes a toll on the client's sleep. Communication and social support are only peripherally related to episodes of intrusion. Intrusion will certainly affect the client's vital signs, but these changes are unlikely to be as problematic as sleep difficulties.

Which statement made by a client diagnosed with posttraumatic stress disorder (PTSD) leads the nurse to believe the client is experiencing dissociative symptoms?

"I describe my feelings like I'm having an out-of-body experience."

Dissociation is a disruption in the normally occurring linkages among subjective awareness, feelings, thoughts, behavior, and memories. A person who dissociates is making himself or herself "disappear." That is, the person has the feeling of leaving his or her body and observing what happens to him or her from a distance and being detached from others. During trauma, dissociation enables a person to observe the event while experiencing no or only limited pain and to protect himself or herself from awareness of the full impact of the traumatic event. Flashbacks are common with PTSD; loud noises associated with the trauma cause flashbacks. Guilt is common for survivors.

The nurse is assessing a client who recently experienced their first panic attack while at the grocery store. What question should the nurse ask to identify complications of the disorder?

"Do you have any problems going out alone to public places?"

To identify complications of the disorder when assessing a client who recently experienced the client's first panic attack while at a grocery store, the psychiatric nurse asks, "Do you have any problems going out alone to public places?"

Which medication classification has been found to be effective in reducing or eliminating panic attacks?

Which should be included in a teaching plan for a client prescribed a benzodiazepine?

Rise slowly from a lying or sitting position

Clients taking a benzodiazepine should rise slowly from a lying or sitting position. The client should drink adequate fluids, avoid caffeine, and not stop taking the drug abruptly.

Which nursing assessment is most appropriate for an older client presenting with reports of generalized anxiety?

Assess for depression

Late-onset generalized anxiety disorder (GAD) is usually associated with depression. Although less common, panic attacks can occur in later life and are often related to depression or a physical illness such as cardiovascular, GI, or chronic pulmonary diseases. While the remaining options are appropriate, they are not associated with the possible comorbid conditions of GAD.

A nurse is assessing a client with anxiety. Which signs and symptoms would the nurse attribute to sympathetic nervous stimulation? Select all that apply.

Heart racing, Hypertension

The mental health nurse is gathering a health history on a new client. The nurse has difficulty getting the client's attention, and the client is pacing the floor and concerned only with stating that they are about to die. The nurse would classify this level of anxiety as what?

Severe

This client is exhibiting signs of severe anxiety. At this level, the perceptual field is narrowed to only one detail or scattered details. The client may pace or exhibit other physical behaviors to relieve the anxiety (usually without success), and the client will not respond to redirection. With moderate anxiety, behaviors are less severe. The client can still process information, and while they may have difficulty concentrating, redirection is typically achievable. Mild anxiety causes the client to have increased alertness to inner feelings or the environment, and physical symptoms are mild. During euphoria, the client experiences an exaggerated feeling of well-being that is not directly proportional to a specific circumstance or situation.

Which nursing intervention is focused on the primary goal of anxiety management and treatment?

Assessing the client's ability to implement stress management techniques effectively

For people with anxiety disorders, it is important to emphasize that the goal is effective management of stress and anxiety, not the total elimination of anxiety. Learning anxiety management techniques and effective methods for coping with life and its stresses is essential for overall improvement in life quality. Although medication is important to relieve excessive anxiety, it does not solve or eliminate the problem entirely. While assessment is appropriate, it is not directly associated with the management and treatment of the original disorder.

Which term describes feelings of being disconnected from oneself as seen in a panic attack?

Which is the primary concern for a client with panic-level anxiety?

A nurse determines that a client who is experiencing anxiety is using relief or primitive survival behaviors. The nurse determines that the client is experiencing which degree of anxiety?

Which level of anxiety helps the client focus the client's attention to learn, problem solve, think, act, feel, and protect himself or herself?

Mild

In mild anxiety, sensory stimulation increases and helps the client focus the client's attention to learn, solve problems, and think. Moderate anxiety causes the client to have difficulty concentrating independently, but he or she can be redirected to the topic. Severe anxiety causes the client to have a reduced perceptual field and he or she cannot complete tasks. Panic anxiety reduces the perceptual field to focus on the self, and the client cannot process any environmental stimuli.

Which statement, made by a client diagnosed with an anxiety disorder, should trigger the nurse's concern about the client's understanding of the use of defense mechanisms?

"When I have a problem, I just deny it until it goes away."

The dependence on one or two defense mechanisms also can inhibit emotional growth, lead to poor problem-solving skills, and create difficulty with relationships. Denial should not be used to deal with all of one's problems. None of the remaining options present untrue or troubling statements regarding defense mechanisms.

A patient with anxiety disorder has excessive anxiety and worries about multiple life circumstances. For how long would this patient experience these feelings before the anxiety disorder would be considered chronic and generalized?

6 months

For generalized anxiety disorder, the diagnostic criteria listed include unrealistic or excessive anxiety and worry about two or more life circumstances for 6 months or more, during which time these concerns exist for a majority of days.

Which statement by the nurse demonstrates an understanding of the role automatisms have in a panic attack?

"The client taps her fingers very rapidly when she is feeling anxious."

Which would be an appropriate intervention for a client experiencing an anxiety attack?

Staying with the client and speaking in short sentences

Appropriate nursing interventions for an anxiety attack include using short sentences, staying with the client, decreasing stimuli, remaining calm, and medicating as needed. Leaving the client alone, turning on a stereo or lights, and opening windows may increase the client's anxiety.

Which would not be included in the plan of care for a client diagnosed with acute anxiety?

Touching the client in an attempt to comfort the client

The emergency nurse must establish rapport and trust with the anxious client before using therapeutic touch. Touching an anxious client may actually increase anxiety. Trust can be established by approaching the client in a calm and confident manner; providing a place that is quiet, safe, and private; and encouraging the client to verbalize feelings and concerns.

A group of nursing students are reviewing signs and symptoms of anxiety. The students demonstrate a need for additional review when they identify what?

Tearfulness

The clinical symptoms of anxiety are numerous. They are generally classified as physiologic, psychological or emotional, behavioral, and intellectual or cognitive responses to stress. The clinical symptoms may vary according to the level of anxiety exhibited by the client. Tearfulness and sadness are symptoms of depression, not of anxiety.

The nurse is teaching relaxation techniques to a client with obsessive-compulsive disorder (OCD). When does the nurse teach relaxation techniques to the client?

When the client is experiencing low anxiety levels.

The nurse teaches relaxation techniques when the client's anxiety level is low. This helps the client learn the technique more effectively and the client begins to use these techniques when anxiety increases. The nurse does not interrupt the client during a repetitive ritual because it agitates the client. The nurse does not teach relaxation techniques after the client has taken medication. The client has disturbed sleep so the nurse promotes a comfortable and quiet environment for the client.

What signs of stabilization does the nurse recognize during the follow-up visit of a client undergoing behavior therapy for obsessive-compulsive disorder (OCD)?

The client completes daily routine within a specified time.

The client who has achieved stabilization following behavior therapy for OCD is able to complete the daily routine within a specified time. The other outcomes are expected in a client in the immediate phase of behavior therapy. In that phase, the client is able to identify stresses and anxieties, talk to the nurse about conflicting thoughts and fears and, with nursing staff help, recognize personal strengths and abilities.

The nurse is caring for clients with obsessive-compulsive disorder (OCD). Which progressive and debilitating disorder is most commonly seen with a late onset?

What question by the nurse is focused on identifying oniomaniac tendencies in a client diagnosed with depression?

"Do you get enjoyment out of all the clothes you buy?"

The nurse is caring for a client who performs ritualistic hand washing and cleaning for about 30 minutes several times a day. What does the nurse tell the client's partner about caring for this client?

Monitor own health and anxiety levels.

The nurse asks the client's partner to monitor the partner's own health and anxiety levels. The partner may benefit from an occasional break in the routine. The client must undergo therapy to complete daily activities without assistance. Diverting the client's attention to other activities or ignoring the client's behavior does not help either of them. The partner must understand the client's problem and encourage the client to undergo behavior therapy and take medications.

Which statement made by the nurse to the family of a client diagnosed with obsessive-compulsive disorder (OCD) demonstrates the best general understanding of the chronic nature of the disorder and its management?

"It's important to know that the symptoms will intensify during periods of stress."

OCD is a chronic, progressive disease. Symptoms wax and wane over time, increasing during periods of stress. While the other statements are accurate, they do not provide the most general, encompassing information regarding the management of this chronic, progressive disorder.

What intervention does the nurse perform to assist the client in decreasing the frequency of repetitive behaviors?

Assist the client to keep a record of when time is used in performing activities.

The nurse should teach the client to keep a record of the frequency of and time used to perform activities. This helps the client to observe the decrease, an improvement in the condition. The client who avoids people and has limited social contact is taught conversation and attentive listening. The nurse helps the client who needs long-therapy to identify supportive resources in the community. The client is usually agitated when repeated behaviors are interrupted by others in an attempt to reduce the time taken for activities.

Which goal is appropriate for the client being treated for obsessive-compulsive disorder with response prevention therapy?

The client will experience notably less anxiety when engaged in delaying the ritual within 3 months.

Response prevention focuses on delaying or avoiding performance of rituals. The client learns to tolerate the thoughts and the anxiety and to recognize that it will recede without the disastrous imagined consequences. Other techniques, such as deep breathing and relaxation, can also assist the person to tolerate and eventually manage the anxiety. Exposure involves assisting the client to deliberately confront the situations and stimuli that he or she usually avoids

A teenager and the teenager's parents visit the clinic to discuss the teen's skin picking. There are many bleeding wounds and various stages of scabs located up and down both arms. The parents are very upset about this behavior and want it to stop. Which would the health care provider document?

Excoriation disorder

Excoriation disorder (skin picking) is the inability to stop recurrent picking at skin for emotional release or anxiety release. Body dysmorphic disorder is a preoccupation with slight or imagined physical defects that are not apparent to others. There is not enough information to diagnose disrupted family dynamics or control issues within the family unit.

The nurse is assessing the physiological effects of severe obsessive-compulsive disorder (OCD) in a client. What does the nurse expect to find during assessment?

The client is unable to maintain adequate personal hygiene.

Rationale: In severe OCD, the client is unable to complete routine tasks because of compulsive ritual behaviors. A lot of time is spent on performing rituals and the client may not have enough time to sleep. The client is so obsessed with thoughts and compulsive behaviors that physical needs such as sleep, food, drink, and hygiene are neglected. Thus, the client may report unwanted weight loss. Rituals also interfere with the client's ability to complete activities quickl

A client with obsessive-compulsive disorder (OCD) states making a concerted effort to reduce the frequency and duration of rituals. What intervention should the nurse include to assist in these efforts?

Teach the client nonpharmacologic relaxation techniques

Reducing the frequency of rituals for a person with OCD causes anxiety. Clients consequently benefit from learning techniques that can reduce their stress in a healthy way. Mood stabilizers are not typically used in the treatment of OCD, and nurses do not normally facilitate the performance of rituals. The client is likely aware of the negative consequences of obsessions and rituals, as evidence by efforts to eliminate them.

A client's older parent has been diagnosed with hoarding disorder. What does the nurse instruct the client about the parent's hoarding disorder?

Treatment may involve community agencies.

The treatment for hoarding disorder in the older adult may involve multiple community agencies besides medications and behavior therapy. Hoarding disorder is an obsessive-compulsive disorder (OCD) with a late-age onset; any other recently acquired OCD in the older client may be a degenerative disorder or the result of an injury to the basal ganglia. Long-term, not short-term, treatment can result in a successful outcome.

When assessing the insight and self-concept of a client with obsessive-compulsive disorder (OCD), what does the nurse note?

The client has a fear of "going crazy."

Clients with OCD express concern that they may be "going crazy." Feelings of powerlessness to control the obsessions or compulusions contribute to their low self-esteem. These clients also feel that they could control the thoughts and behaviors if they had stronger willpower. These clients are able to make sound judgments but are unable to act on them. Clients with OCD are aware that the intrusive images and thoughts are irrational, but they cannot control the overwhelming anxiety.

Which medication does the nurse anticipate the health care provider will prescribe for a client who is beginning treatment for obsessive-compulsive disorder (OCD)?

A client spends hours stacking and unstacking towels. The client is repeatedly checking to make sure that the towels are in order of color. What term is used to identify this behavior?

Compulsion

Compulsions are ritualistic or repetitive behaviors or mental acts that a person carries out continuously in an attempt to neutralize anxiety. A phobia is an illogical, intense, persistent fear of a specific object or a social situation that causes extreme distress and interferes with normal functioning. An obsession is a recurrent, persistent, intrusive, and unwanted thought, image, or impulse that causes marked anxiety and interference with interpersonal, social, or occupational function. Derealization is sensing that things are not real.

What interventions does the nurse use to promote therapeutic communication with the client diagnosed with obsessive-compulsive disorder (OCD)?

Explore the thoughts and feelings that trouble the client.

The nurse discusses the client's thoughts and feelings in as much detail as possible. This helps to relieve the client of some of the "burden" the client has been keeping to the self. The client is aware that the anxiety is irrational. The nurse validates the irresistible feelings that the client experiences but assures the client that these can be controlled. OCD clients tend to hide their rituals and obsessions from friends and family. However, discussing them with the nurse is an important step in treatment.

The nurse is assessing a client who spends several hours arranging and rearranging items around the house. What does the nurse anticipate is the cause of this compulsive behavior?

The client is preoccupied with perfection.

The client who is obsessed with perfection performs compulsive rituals such as arranging and rearranging items around the house. The client who has a fear of contamination is obsessed with cleanliness. This client repeatedly washes hands and cleans and scrubs the surroundings. The client who is obsessed with blasphemous thoughts engages in repeated prayers or confession.

The nurse is assisting a client with behavior therapy for OCD. What nursing intervention may help enhance self-esteem?

Provide opportunities for the client to accomplish an activity.

The nurse should provide the client with the opportunity to participate in activities that are easily accomplished or enjoyed by the client. The nurse teaches the client to confront situations that activate compulsive behavior during the "exposure" training. The nurse does not interrupt the client when performing a ritualistic behavior. This elevates anxiety levels in the client. Deep breathing exercises are performed when anxiety levels rise.

The nurse is assessing a teenage client with onychophagia. What does the nurse teach the parent about the disorder?

Treatment with selective serotonin reuptake inhibitor (SSRI) antidepressants is effective.

The nurse is caring for a client undergoing cognitive behavior therapy for obsessive-compulsive disorder. How does the cognitive model describe the client's thought process? Select all that apply.

The client overestimates the threats caused by the thoughts., The client has intolerance for uncertainty., The client wants to control own thoughts.

According to the cognitive model, the person believes that "if I think, it will happen." Therefore, the client wants to control the client's own thoughts. This client tries to be perfect and has intolerance for uncertainty. The client feels threatened by the thoughts. All this causes an increased anxiety in the client leading to some compulsive ritualistic behavior. As per the cognitive model, the client's thoughts are influenced by an inflated sense of responsibility. This may be a result of strict moral or religious upbringing.

Which statement by the nurse providing care for a client diagnosed with obsessive-compulsive disorder (OCD), indicates a need for additional education regarding the client's ritualistic hand washing?

"Let me help you find something less time consuming to do to manage your anxiety."

The nurse is assessing a client recently diagnosed with obsessive-compulsive disorder (OCD). What does the nurse tell the client about the onset of the disorder?

Early onset may indicate family history of OCD.

Early onset of OCD indicates the likelihood of a family history of OCD. OCD starts in childhood especially in males. In females the onset is in the 20s. OCD is diagnosed only when the client's compulsive behavior interferes with the client's personal, social, and occupational function.

While planning care for a child who has excoriation disorder, which would be the priority NANDA nursing diagnosis?

Impaired skin integrity

The nursing diagnoses applied to patients with obsessive-compulsive disorder can run the gamut from the primary diagnosis of anxiety to other physiologic disturbances of the compulsion, such as impaired skin integrity, which may result from continuous hand washing or picking at the skin

The nurse is caring for a client with obsessive-compulsive disorder (OCD). What are the expected outcomes for the client who has been stabilized by medication and behavior therapy

Continue follow-up therapy as needed.

Clients with OCD who have been stabilized by medication and behavior therapy may experience long-term difficulties in dealing with obsessive thoughts. These clients are encouraged to continue follow-up therapy. The expected outcome for clients in the stabilization phase of therapy is verbalizing knowledge of illness and treatment plan. In the immediate phase of therapy, clients should be able to list and review strengths and abilities with the nursing staff. These clients should also be able identify stresses and anxieties to enable the nurse to develop a plan of care.

The nurse is interviewing the parents of a child who is exhibiting obsessive-compulsive disorder (OCD). The nurse would anticipate that the parents would report the occurrence of which situation with the child?

Failing classes due to a lack of concentration.

Assessment reveals intact intellectual functioning. The client may describe difficulty concentrating or paying attention when obsessions are strong. Because children subscribe to myths, superstition, and magical thinking, obsessive and ritualistic behaviors may go unnoticed. Behaviors such as touching every third tree, avoiding cracks in the sidewalk, or consistently verbalizing fears of losing a parent in an accident may have some underlying pathology but are common behaviors in childhood. Typically, parents notice that a child's grades begin to fall as a result of decreased concentration and great amounts of time spent performing rituals. Isolating themselves, staring off into space, and being nervous could be considered normal behavior at certain developmental ages.

Which medication is used to control the extrapyramidal effects associated with antipsychotic medications?

Benzotropine

Benzotropine is an anticholinergic drug used to relieve drug-induced extrapyramidal adverse effects, such as muscle weakness, involuntary muscle movement, pseudoparkinsonism, and tardive dyskinesia.

A client with schizophrenia is hearing voices that tell the client to kill the self. What term is used to identify this type of false sensory perception?

Hallucination

A hallucination is a sensory perception, such as hearing voices and seeing objects, that only the client experiences. A delusion is a false belief. Flight of ideas refers to a speech pattern in which the client skips from one unrelated subject to another. Ideas of reference refers to the mistaken belief that someone or something outside the client is controlling the client's ideas or behavior.

The nurse is evaluating the plan of care for a client with schizophrenia. Which observation best suggests that the plan has been effective?

The client has resumed employment and attends social functions.

Major goals for the care of a client with schizophrenia are to experience improved thought processes and fewer psychotic symptoms, to not engage in violent behavior, to acquire improved social skills and engage in satisfying social interaction, and to gain knowledge about the disease process and treatment. Increased conversations with the staff is unrelated to the overall plan of care for the client with schizophrenia.

Which medication classification has been most effective in treating akathisia?

A client diagnosed with schizophrenia tells the nurse, "I hear the voice of Elvis." Which is the most therapeutic response by the nurse?

"I don't hear the voice, but I know you hear what sounds like a voice."

Which is a nonneurologic side effect of antipsychotic medications?

Weight gain

Weight gain is a nonneurologic side effect of antipsychotic medications.

A client is being released from the inpatient psychiatric unit with a diagnosis of schizophrenia and treatment with antipsychotic medications. After teaching the client and family about managing the disorder, the nurse determines that the education was effective when they state that which should be reported immediately?

A client who has a major depressive episode tells the nurse that, for the past 2 weeks, the client has been hearing voices and at times thinks that someone is following the client. A history reveals that the client has had these alternating symptoms before. The client also has experienced time with neither of these symptoms and has been able to function adequately. The nurse interprets these findings as suggesting:

Schizoaffective disorder

Schizoaffective disorder is characterized by intervals of intense symptoms between quiescent periods. At times, there are symptoms of schizophrenia, and at other times, there seems to be a mood disorder. Because the symptoms alternate with quiet periods, schizophrenia, either paranoid or undifferentiated, would not apply. A brief psychotic episode involves symptoms of at least 1 day but less than 1 month, and the onset is sudden. The client generally experiences emotional turmoil or overwhelming confusion and rapid intense shifts of affect.

A married couple arrives at the outpatient clinic. Upon assessment, the nurse finds that the couple believes that the police have been following them and tapping their phones for 2 months. This couple most likely suffers from which disorder?

Folie à deux

Shared psychotic disorder, or folie à deux, involves two individuals who have a close relationship and share the same delusion. This occurrence is attributed to the strong influence of the more dominant person. It is seen more frequently in women who are isolated by language, culture, or geography. Such persons are often related by blood or marriage and have lived together for an extended period of time. Contributing factors include old age, low intelligence, sensory impairment, cerebrovascular disease, and alcohol abuse. This disorder has been diagnosed in twins and individuals, both of whom had a chronic psychotic disorder. This disorder also has occurred in a group of individuals or in families in which the parent is the primary case (inducer).

A client tells the nurse that the client has bugs in the client's brain and asks the nurse if the nurse can see them. Which response by the nurse is most therapeutic?

"No, I don't see any bugs. That sounds scary for you."

The person who hallucinates is preoccupied and frightened by what he or she hears or sees. The hallucination is real to the client, and the nurse cannot argue away, dismiss, or ignore it. Although the hallucination is real to the client, nurses make it clear that they do not hear the voices or see the visual images. Nurses do, however, communicate concern that the client is bothered, upset, or frightened by the hallucination.

A client diagnosed with schizophrenia states to the nurse, "My intestines are being eaten by snakes." This statement represents which type of delusion?

Somatic delusion

Somatic delusions are generally vague and unrealistic beliefs about the client's health or bodily functions. Persecutory delusions involve the client's belief that "others" are planning to harm the client or are spying, following, or belittling the client in some way. Grandiose delusions are characterized by the client's claim to associate with famous people or celebrities or the client's belief that he or she is famous or capable of great feats. Referential delusions or ideas of reference involve the client's belief that television broadcasts, music, or newspaper articles have special meaning for him or her.

A client is watching the news and tells the nurse that the newscaster is sending a message to the client. What term is used to identify this symptom?

What term is used to describe the speech pattern being used when the client imitates or repeats what the nurse is saying?

Echolalia

Echolalia is the client's imitation or repetition of what the nurse says. Neologisms are words invented by the client. Clang associations are ideas that are related to one another based on sound or rhyming rather than meaning. A word salad is a combination of jumbled words and phrases that are disconnected or incoherent and make no sense to the listener.

A client is being seen in the health clinic. The nurse observes a shuffling gait, drooling, and slowness of movement. The client is currently taking an antipsychotic for treatment of schizophrenia. The nurse knows that which side effect is occurring?

Pseudoparkinsonism

Pseudoparkinsonism is exhibited by a shuffling gait, drooling, and slowness of movement. Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles. Akathisia causes restlessness, anxiety, and jitteriness. Neuroleptic malignant syndrome causes rigidity, fever, hypertension, and diaphoresis.

A client has been taking neuroleptic medications for many years as a treatment for schizophrenia. The client is exhibiting tongue protrusion, facial grimacing, and excessive blinking. These manifestations are characteristic of which extrapyramidal side effects (EPS)?

Tardive dyskinesia

Unusual movements of the tongue, neck, and arms suggest tardive dyskinesia, an adverse reaction to neuroleptic medication. Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles. Neuroleptic malignant syndrome causes rigidity, fever, hypertension, and diaphoresis. Akathisia causes restlessness, anxiety, and jitteriness.

A client diagnosed with schizophrenia states, "I want to go home, go home, go home." This is an example of which speech pattern?

Which speech pattern is exhibited by the client stating, "I will take a pill if I go up the hill but not if my name is Jill, I don't want to kill?"

Clang association

Clang associations are ideas that are related to one another based on sound or rhyming rather than meaning.

A client diagnosed with schizophrenia has been prescribed clozapine. Which is a potentially fatal side effect of this medication?

Agranulocytosis

Agranulocytosis is manifested by a failure of the bone marrow to produce adequate white blood cells

Application by physician for psychiatric assessment. The physician has examined the person and feels he/she needs to be seen at a psychiatric facility. Form must be signed within 7 days of seeing patient

Notice to person. This is given to the person and explains why the doctor wants he/she to be seen in a psych facility and they have the right to contact a lawyer

Certificate of involuntary admission. The person on a form 1 has been examined and the doctor feels they are too ill to be discharged from the psych hospital and this form keeps them there

Notice to patient. This explains that the person is not going to be released after 72 hours and will remain at the psych hospital

Certificate of renewal. Before the form 3 expires (2 weeks from date of signature) the doctor feel the person is still too ill to be released from the hospital

Which symptom would the nurse assess in a patient with PTSD?

Which of the following are symptoms of posttraumatic stress disorder select all that apply?

What are the signs and symptoms that would distinguish a person with posttraumatic stress disorder?

Which symptoms must be present to make an accurate diagnosis of PTSD?