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HESI RN EXIT CASE STUDY - SCHIZOPHRENIA
1. Based on this assessment, what is the most important nursing interven- tion?
A. Establish rapport and trust.
B. Assess for hallucinations.
C. Maintain adequate social space.
D. Plan to give a PRN antipsychotic
ANS: A. Establish rapport and trust.
2. What is the most accurate assessment if the client believes that the health- care providers are FBI
agents and that there are cameras in his apartment to monitor his moves?
A. Hallucinations.
B. Delusions.
C. Confabulation.
D. Thought broadcasting
ANS: B. Delusions.
3. Which behavior is characteristic of a thought disorder?
A. Blunted affect.
B. Irritability.
C. Lability of mood.
D. Preoccupation with guilty feelings
ANS: A. Blunted affect.
4. The nurse understands that schizophrenia can be differentiated from psy- chosis by which
assessment?
A. Disorganized speech.
B. Disorganized behavior.
C. Auditory hallucinations.
D. Negative symptoms
ANS: D. Negative symptoms.
5. Which finding depicts negative symptoms of schizophrenia?
A. Difficulty sitting still.
B. Rapid and disorganized speech.
C. Flat affect and social inattentiveness.
D. Delusional statements
ANS: C. Flat affect and social inattentiveness.
6. Which nursing problem has priority?
A. Ineffective community coping.
B. Disturbed thought processes.
D. Guarded and suspicious
ANS: C. Violence towards father.
10. If a client who has voluntarily chosen to be hospitalized should want to leave the hospital, which
assessment would be most important in deciding to release the client against medical advice (AMA)?
A. Mental status of client.
B. Reason that client wants to leave.
C. Response to medications.
D. Potential danger to self or others
ANS: D. Potential danger to self or others.
11. Which nursing action is best?
A. Obtain a prescription to begin the Cogentin.
B. Monitor Sam for medication side effects.
C. Ask Sam if he had any side effects from the Prolixin.
D. Do not give the Prolixin and document the reason
ANS: A. Obtain a prescription to begin the Cogentin.
12. Which side effects would the nurse most likely observe with fluphenazine (Prolixin), a traditional
antipsychotic?
A. High extrapyramidal effects, low anticholinergic effects.
B. High anticholinergic effects and low extrapyramidal effects.
C. Risk for agranulocytosis, fever, and elevated blood pressure.
D. Blood dyscrasias such as thrombocytopenia
ANS: A. High extrapyramidal effects, low anticholinergic effects.
13. What type of reaction should the nurse suspect?
A. Akathisia.
B. Dystonia.
C. Parkinsonism.
D. Synergistic
ANS: B. Dystonia.
14. How should the nurse respond?
A. Everything is confidential, so I doubt this will happen.
B. I know that this is probably unlikely. What do you think?
C. What if the limousine does not get here?
D. It sounds like you are anxious to leave here
ANS: D. It sounds like you are anxious to leave here.
15. How should the nurse interpret Sam's belief that he is a famous movie star and that a limousine
driver will arrive to get him later in the day?
A. Psychotic thinking.
B. Tell me about how you're feeling.
C. Are you hearing any voices?
D. I notice that you talk to yourself
ANS: C. Are you hearing any voices?
18. Which group is most therapeutic for Sam?
A. Structured medication group.
B. Unstructured group about personal issues.
C. Psychoeducational group about self-esteem.
D. Supportive therapy group
ANS: A. Structured medication group.
19. Based on Sam's statement, which nursing problem should the nurse doc- ument for the group
progress note?
A. Ineffective denial.
B. Knowledge deficit.
C. Ineffective coping.
D. Risk for adherence
ANS: D. Risk for adherence.
20. Which understanding is most accurate?
A. There is an imbalance of the brain neurotransmitters dopamine and sero- tonin.
B. There is a marked increase in brain volume, which causes abnormal func- tioning.
C. Schizophrenia develops when at least one parent or distant relative has schizophrenia.
D. This brain disorder has many predisposing factors and a biological basis.-
: D. This brain disorder has many predisposing factors and a biological basis.
21. How should the nurse explain symptom triggers to the clients?
A. Symptom triggers are stressors that lead to increased difficulty handling anger.
B. Symptom triggers can be related to health, the environment, or attitudes.
C. Symptom triggers are behaviors that lead to medication noncompliance.
D. Symptom triggers are stressors caused by hospitalization
ANS: B. Symptom triggers can be related to health, the environment, or attitudes.
22. Which explanations are best?
A. Knowing symptom triggers and how to manage them can help prevent relapse.
B. Identifying symptom triggers may prevent the risk of violence and promote
C. Complete blood count.
D. Screening for tardive dyskinesia
ANS: A. Baseline weight.
26. Which side effect(s) are characteristic of atypical antipsychotics?
A. Increased tardive dyskinesia.
B. Less incidence of weight gain.
C. Fewer extrapyramidal effects.
D. More extrapyramidal effects.
E. Dry mouth
ANS: C. Fewer extrapyramidal effects. E. Dry mouth.
27. The nurse understands that an atypical antipsychotic like olanzapine (Zyprexa) requires
what period of time to reach a steady state?
A. 2 weeks.
B. 4 or more weeks.
C. 1 week.
D. 2 days
ANS: C. 1 week.
28. Which medication with potentially life-threatening side effects should the nurse expect the
healthcare provider to prescribe for clients who do not respond to the use of other antipsychotics?
A. Clozapine (Clozaril).
B. Haloperidol decanoate (Haldol decanoate).
C. Fluphenazine decanoate (Prolixin decanoate).
D. Perfenazine (Trilafon)
ANS: A. Clozapine (Clozaril).
29. Which speech process should the nurse document on the daily mental status exam record?
A. Loose associations.
B. Tangential.
C. Monotone.
D. Poverty of speech
ANS: D. Poverty of speech.
30. Which thought process does this exemplify?
A. Concrete thinking.
C. How do you feel about your father now?
D. Do you think about hurting anyone now?: D. Do you think about hurting anyone now?
33. What will be the most important group activity to promote wellness in the community?
A. Explore symptom management.
B. Review education about medications.
C. Practice social skills.
D. Identify community coping resources
ANS: A. Explore symptom management.
34. What is the first step the nurse should use to teach about effective symp- tom management?
A. Talk about specific support systems.
B. Review current ways to manage symptoms.
C. Identify problem symptoms.
D. Discuss other ways to manage symptoms
ANS: C. Identify problem symptoms.
35. After implementing the first step, what step is taken next?
A. Identify current ways to manage symptoms.
B. Talk about specific support systems.
C. Discuss other ways to manage symptoms.
D. Develop a new symptom management plan
ANS: A. Identify current ways to man- age symptoms.
36. Which strategy is best for clients who hear voices?
A. Avoid certain situations.
B. Smoke more cigarettes.
C. Decrease caffeine use.
D. Take more medication
ANS: A. Avoid certain situations.
37. What is the most common cause of relapse in a client with schizophrenia?
A. Symptom management.
B. Medications.
C. Lack of community support.
D. Health practices
ANS: B. Medications.
38. What is the nurse's best response?
A. This can happen even if you are taking medications every day.
