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NCLEX RN LATEST 2025 EXAM QUESTIONS AND ANSWERS WITH COMPLETESOLUTIONS AND EXPLANATIONS…GR, Exams of Nursing

Question 1 Yesterday, a client with schizophrenia began treatment with haloperidol (Haldol). Today, the nurse notices that the client is holding his head to one side and complaining of neck and jaw spasms. What should the nurse do? A Assume that the client is posturing. B Tell the client to lie down and relax. Evaluate the client for adverse reactions to haloperidol. Put the client on the list for the physician to see tomorrow Question 1 Explanation: An antipsychotic agent, such as haloperidol, can cause muscle spasms in the neck, face, tongue, back, and sometimes legs as well as torticollis (twisted neck position). The nurse should be aware of these adverse reactions and assess for related reactions promptly. Although posturing may occur in clients with schizophrenia, it isn’t the same as neck and jaw spasms. Having the client relax can reduce tension-induced muscle st

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NCLEX RN LATEST 2025 EXAM
QUESTIONS AND ANSWERS
WITH COMPLETE SOLUTIONS
AND EXPLANATIONS…GRADE
A+
Question 1
Yesterday, a client with schizophrenia began treatment with haloperidol (Haldol). Today, the nurse notices that the
client is holding his head to one side and complaining of neck and jaw spasms. What should the nurse do?
A Assume that the client is posturing.
B Tell the client to lie down and relax.
Evaluate the client for adverse reactions to haloperidol.
Put the client on the list for the physician to see tomorrow
Question 1 Explanation:
An antipsychotic agent, such as haloperidol, can cause muscle spasms in the neck, face, tongue, back, and sometimes
legs as well as torticollis (twisted neck position). The nurse should be aware of these adverse reactions and assess for
related reactions promptly. Although posturing may occur in clients with schizophrenia, it isn’t the same as neck and
jaw spasms. Having the client relax can reduce tension-induced muscle stiffness but not drug-induced muscle spasm
s.
When a client develops a new sign or symptom, the nurse should consider an adverse drug reaction as the possible
cause and obtain treatment immediately, rather than have the client wait.
Question 2
WRONG
The nurse knows that the physician has ordered the liquid form of the drug chlorpromazine (Thorazine) rather than the
tablet form because the liquid:
has a more predictable onset of action.
B
produces fewer anticholinergic effects.
produces fewer drug interactions.
D
has a longer duration of action.
Question 2 Explanation:
A liquid phenothiazine preparation will produce effects in 2 to 4 hours. The onset with tablets is unpredictable.
Question 3
WRONG
Nursing care for a client with schizophrenia must be based on valid psychiatric and nursing theories. The nurse’s
interpersonal communication with the client and specific nursing interventions must be:
clearly identified with boundaries and specifically defined
roles.
warm and nonthreatening.
centered on clearly defined limits and expression of empathy.
Que
A fle
has a
time
the b
fears
interv
flexible enough for the nurse to adjust the plan of care as the
situation warrants.
stion 3 Explanation:
xible plan of care is needed for any client who behaves in a suspicious, withdrawn, or regressed manner or who
thought disorder. Because such a client communicates at different levels and is in control of himself at various
s, the nurse must be able to adjust nursing care as the situation warrants. The nurse’s role should be clear; however,
oundaries or limits of this role should be flexible enough to meet client needs. Because a client with schizophrenia
closeness and affection, a warm approach may be too threatening. Expressing empathy is important, but centering
entions on clearly defined limits is impossible because the client’s situation may change without warning.
Question 4
WRONG
The definition of nihilistic delusions is:
A
a false belief about the functioning of the body.
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Download NCLEX RN LATEST 2025 EXAM QUESTIONS AND ANSWERS WITH COMPLETESOLUTIONS AND EXPLANATIONS…GR and more Exams Nursing in PDF only on Docsity!

NCLEX RN LATEST 2025 EXAM

QUESTIONS AND ANSWERS

WITH COMPLETESOLUTIONS

AND EXPLANATIONS…GRADE

A+

Question 1 Yesterday, a client with schizophrenia began treatment with haloperidol (Haldol). Today, the nurse notices that the client is holding his head to one side and complaining of neck and jaw spasms. What should the nurse do?

A Assume^ that^ the^ client^ is posturing.

B Tell^ the^ client^ to^ lie^ down and^ relax.

Evaluate the client for adverse reactions to haloperidol. Put the client on the list for the physician to see tomorrow Question 1 Explanation: An antipsychotic agent, such as haloperidol, can cause muscle spasms in the neck, face, tongue, back, and sometimes legs as well as torticollis (twisted neck position). The nurse should be aware of these adverse reactions and assess for related reactions promptly. Although posturing may occur in clients with schizophrenia, it isn’t the same as neck and jaw spasms. Having the client relax can reduce tension-induced muscle stiffness but not drug-induced muscle spasm s. When a client develops a new sign or symptom, the nurse should consider an adverse drug reaction as the possible cause and obtain treatment immediately, rather than have the client wait. Question 2 WRONG The nurse knows that the physician has ordered the liquid form of the drug chlorpromazine (Thorazine) rather than the tablet form because the liquid: has a more predictable onset of action.

B produces^ fewer^ anticholinergic^ effects.

produces fewer drug interactions.

D has^ a^ longer^ duration^ of^ action.

Question 2 Explanation: A liquid phenothiazine preparation will produce effects in 2 to 4 hours. The onset with tablets is unpredictable. Question 3 WRONG Nursing care for a client with schizophrenia must be based on valid psychiatric and nursing theories. The nurse’s interpersonal communication with the client and specific nursing interventions must be:

A

clearly identified with boundaries and specifically defined roles.

B warm^ and^ nonthreatening.

centered on clearly defined limits and expression of empathy. Que A fle has a time the b fears interv flexible enough for the nurse to adjust the plan of care as the situation warrants. stion 3 Explanation: xible plan of care is needed for any client who behaves in a suspicious, withdrawn, or regressed manner or who thought disorder. Because such a client communicates at different levels and is in control of himself at various s, the nurse must be able to adjust nursing care as the situation warrants. The nurse’s role should be clear; however, oundaries or limits of this role should be flexible enough to meet client needs. Because a client with schizophrenia closeness and affection, a warm approach may be too threatening. Expressing empathy is important, but centering entions on clearly defined limits is impossible because the client’s situation may change without warning. Question 4 WRONG The definition of nihilistic delusions is:

A a^ false^ belief about^ the^ functioning^ of^ the^ body.

ve affected the ability to perform self-care te ADLs with the assistance of staff members, g items and clothing. This goal promotes realistic l, the nurse can set new goals that focus on the ly, completing them independently. The client’s d only foster dependence. onality disorder experience excessive social anxiety that can lead to paranoid thoughts. mmon, although these clients may experience agitation with anxiety. Their behavior is ned affect, regardless of the situation. These clients demonstrate a reduced capacity for ips.

B belief^ that^ the^ body is^ deformed^ or^ defective^ in^ a^ specific^ way.

false ideas about the self, others, or the world Que the inability to carry out motor activities. stion 4 Explanation: Nihilistic delusions are false ideas about the self, others, or the world. Somatic delusions involve a false belief about the functioning of the body. Body dysmorphic disorder is characterized by a belief that the body is deformed or defective in a specific way. Apraxia is the inability to carry out motor activities. Question 5 WRONG A client who has been hospitalized with disorganized type schizophrenia for 8 years can’t complete activities of daily living (ADLs) without staff direction and assistance. The nurse formulates a nursing diagnosis of Self-care deficient: Dressing/grooming related to inability to function without assistance. What is an appropriate goal for this client?

A

“Client will be able to complete ADLs independently within 1 month.”

B

“Client will be able to complete ADLs with only verbal encouragement within 1 month.” “Client will be able to complete ADLs with assistance in organizing grooming items and clothing within 1 month.” Que The activ who inde clien cond “Client will be able to complete ADLs with complete assistance within 1 month.” stion 5 Explanation: client’s disorganized personality and history of hospitalization ha ities. Interventions should be directed at helping the client comple can provide needed structure by helping the client select groomin pendence. As the client improves and achieves the established goa t completing ADLs with only verbal encouragement and, ultimate ition doesn’t indicate a need for complete assistance, which woul Question 6 WRONG A client is admitted with a diagnosis of schizotypal personality disorder. Which signs would this client exhibit during social situations?

A Aggressive^ behavior

Paranoid thoughts

C Emotional^ affect

Que Clie Agg emo clos e Independence needs stion 6 Explanation: nts with schizotypal pers ressive behavior is unco tionally cold with a flatte or dependent relationsh Question 7 CORRECT A client with delusional thinking shows a lack of interest in eating at meal times. She states that she is unworthy of eating and that her children will die if she eats. Which nursing action would be most appropriate for this client? Telling the client that she may become sick and die unless she eats Paying special attention to the client’s rituals and emotions associated with meals Restricting the client’s access to food except at specified meal and snack times

D Encouraging the^ client^ to^ express^ her^ feelings^ at^ meal^ times

Question 7 Explanation: Restricting access to food except at specified times prevents the client from eating when she feels anxious, guilty, or depressed; this, in turn, decreases the association between these emotions and food. Telling the client she may become sick or die may reinforce her behavior because illness or death may be her goal. Paying special attention to rituals and emotions associated with meals also would reinforce undesirable behavior. Encouraging the client to express feelings at meal times would increase the association between emotions and food; instead, the nurse should encourage her to express feelings at other times.

A

B

of the United States. Their government wouldn’t try to kill you.” “I find it hard to believe that a foreign government or anyone else is trying to hurt you. You must feel frightened by this.” “You’re wrong. Nobody is trying to kill you.” “A foreign government is trying to kill you? Please tell me more about it.” Question 12 WRONG During the assessment stage, a client with schizophrenia leaves his arm in the air after the nurse has taken his blood pressure. His action shows evidence of:

A somatic^ delusions.

waxy flexibility.

C neologisms.

nihilistic delusions. Question 13 WRONG A psychotic client reports to the evening nurse that the day nurse put something suspicious in his water with his medication. The nurse replies, “You’re worried about your medication?” The nurse’s communication is:

A an example^ of^ presenting reality.

B reinforcing^ the^ client’s^ delusions.

focusing on emotional content. a nontherapeutic technique called mind reading. Question 14 WRONG A client is admitted to a psychiatric facility with a diagnosis of chronic schizophrenia. The history indicates that the client has been taking neuroleptic medication for many years. Assessment reveals unusual movements of the tongue, neck, and arms. Which condition should the nurse suspect? Tardive dyskinesia

B Dystonia

Neuroleptic malignant syndrome

D Akathisia

Question 15 WRONG A client with schizophrenia tells the nurse, “My intestines are rotted from the worms chewing on them.” This statement indicates a:

A delusion^ of^ persecution.

Question 14 Explanation: 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. Question 13 Explanation: The nurse should help the client focus on the emotional content rather than delusional material. Presenting reality isn’t helpful because it can lead to confrontation and disengagement. Agreeing with the client and supporting his beliefs are reinforcing delusions. Mind reading isn’t therapeutic. Question 12 Explanation: The correct answer is waxy flexibility, which is defined as retaining any position that the body has been placed in. Somatic delusions involve a false belief about the functioning of the body. Neologisms are invented meaningless words. Nihilistic delusions are false ideas about self, others, or the world. Question 11 Explanation: Responses should focus on reality while acknowledging the client’s feelings. Arguing with the client or denying his belief isn’t therapeutic. Arguing can also inhibit development of a trusting relationship. Continuing to talk about delusions may aggravate the psychosis. Asking the client if a foreign government is trying to kill him may increase his anxiety level and can reinforce his delusions.

D

B delusion^ of^ grandeur.

somatic delusion. jealous delusion. Question 16 WRONG When discharging a client after treatment for a dystonic reaction, the emergency department nurse must ensure that the client understands which of the following?

A Results^ of^ treatment^ are^ rapid and^ dramatic^ but^ may not^ last.

B Although^ uncomfortable,^ this^ reaction^ isn’t^ serious.

The client shouldn’t buy drugs on the street. Que An o of sy airwa The client must take benztropine (Cogentin) as prescribed to prevent a return of symptoms. stion 16 Explanation: ral anticholinergic agent such as benztropine (Cogentin) is commonly prescribed to control and prevent the return mptoms. Dystonic reactions are typically acute and reversible. Dystonic reactions can be life-threatening when y patency is compromised. Lecturing the client about buying drugs on the street isn’t appropriate Question 17 WRONG Which of the following groups of characteristics would the nurse expect to see in the client with schizophrenia? Loose associations, grandiose delusions, and auditory hallucinations Periods of hyperactivity and irritability alternating with depression

C Delusions^ of jealousy^ and^ persecution,^ paranoia,^ and^ mistrust

Sadness, apathy, feelings of worthlessness, anorexia, and weight loss Question 18 WRONG A client is admitted to the psychiatric unit of a local hospital with chronic undifferentiated schizophrenia. During the next several days, the client is seen laughing, yelling, and talking to herself. This behavior is characteristic of:

A delusion.

B looseness^ of^ association.

illusion. hallucination. Question 19 WRONG Most antipsychotic medications exert which of following effects on the central nervous system (CNS)? Question 18 Explanation: Auditory hallucination, in which one hears voices when no external stimuli exist, is common in schizophrenic clients. Such behaviors as laughing, yelling, and talking to oneself suggest such a hallucination. Delusions, also common in schizophrenia, are false beliefs or ideas that arise without external stimuli. Clients with schizophrenia may exhibit looseness of association, a pattern of thinking and communicating in which ideas aren’t clearly linked to one another. Illusion is a less severe perceptual disturbance in which the client misinterprets actual external stimuli. Illusions are rarely associated with schizophrenia. Question 17 Explanation: Loose associations, grandiose delusions, and auditory hallucinations are all characteristic of the classic schizophrenic client. These clients aren’t able to care for their physical appearance. They frequently hear voices telling them to do something either to themselves or to others. Additionally, they verbally ramble from one topic to the next. Periods of hyperactivity and irritability alternating with depression are characteristic of bipolar or manic disease. Delusions of jealousy and persecution, paranoia, and mistrust are characteristics of paranoid disorders. Sadness, apathy, feelings of worthlessness, anorexia, and weight loss are characteristics of depression. Question 15 Explanation: Somatic delusions focus on bodily functions or systems and commonly include delusions about foul odor emissions, insect infestations, internal parasites, and misshapen parts. Delusions of persecution are morbid beliefs that one is being mistreated and harassed by unidentified enemies. Delusions of grandeur are gross exaggerations of one’s importance, wealth, power, or talents. Jealous delusions are delusions that one’s spouse or lover is unfaithful.

B

Question 24 CORRECT A client with chronic schizophrenia who takes neuroleptic medication is admitted to the psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, and diaphoresis. These findings suggest which life-threatening reaction:

A tardive^ dyskinesia.

B dystonia.

neuroleptic malignant syndrome.

D akathisia.

Question 25 CORRECT A client who’s taking antipsychotic medication develops a very high temperature, severe muscle rigidity, tachycardia, and rapid deterioration in mental status. The nurse suspects what complication of antipsychotic therapy?

A Agranulocytosis

B Extrapyramidal^ effects

C Anticholinergic^ effects

Neuroleptic malignant syndrome (NMS) Question 26 WRONG Propranolol (Inderal) is used in the mental health setting to manage which of the following conditions? Antipsychotic-induced akathisia and anxiety

B The^ manic^ phase^ of^ bipolar^ illness^ as^ a^ mood^ stabilizer

C Delusions^ for^ clients^ suffering^ from^ schizophrenia

Que Prop indu used Obsessive-compulsive disorder (OCD) to reduce ritualistic behavior stion 26 Explanation: ranolol is a potent beta-adrenergic blocker and produces a sedating effect; therefore, it's used to treat antipsychotic ced akathisia and anxiety. Lithium (Lithobid) is used to stabilize clients with bipolar illness. Antipsychotics are to treat delusions. Some antidepressants have been effective in treating OCD. Question 27 WRONG A man is brought to the hospital by his wife, who states that for the past week her husband has refused all meals and accused her of trying to poison him. During the initial interview, the client’s speech, only partly comprehensible, reveals that his thoughts are controlled by delusions that he is possessed by the devil. The physician diagnoses paranoid schizophrenia. Schizophrenia is best described as a disorder characterized by: disturbed relationships related to an inability to communicate and think clearly.

B severe^ mood swings^ and periods^ of^ low^ to^ high activity.

multiple personalities, one of which is more destructive than the others. Question 25 Explanation: A rare but potentially fatal condition of antipsychotic medication is called NMS. It generally starts with an elevated temperature and severe extrapyramidal effects. Agranulocytosis is a blood disorder. Anticholinergic effects include blurred vision, drowsiness, and dry mouth. Symptoms of extrapyramidal effects include tremors, restlessness, muscle spasms, and pseudoparkinsonism. Question 24 Explanation: The client’s signs and symptoms suggest neuroleptic malignant syndrome, a life-threatening reaction to neuroleptic medication that requires immediate treatment. Tardive dyskinesia causes involuntary movements of the tongue, mouth, facial muscles, and arm and leg muscles. Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles. Akathisia causes restlessness, anxiety, and jitteriness. Question 23 Explanation: Extrapyramidal effects and the muscle rigidity induced by antipsychotic medications are caused by a low level of dopamine. Dopamine receptor agonists stimulate dopamine receptors and thereby reduce rigidity. They don’t affect norepinephrine or acetylcholine.

D auditory and tactile^ hallucinations.

Question 28 WRONG A client with schizophrenia hears a voice telling him he is evil and must die. The nurse understands that the client is experiencing:

A a^ delusion.

B flight of ideas.

ideas of reference. a hallucination. Question 29 WRONG For several years, a client with chronic schizophrenia has received 10 mg of fluphenazine hydrochloride (Prolixin) by mouth four times per day. Now the client has a temperature of 102° F (38.9° C), a heart rate of 120 beats/minute, a respiratory rate of 20 breaths/minute, and a blood pressure of 210/140 mm Hg. Because the client also is confused and incontinent, the nurse suspects malignant neuroleptic syndrome. What steps should the nurse take? Give the next dose of fluphenazine, call the physician, and monitor vital signs. Withhold the next dose of fluphenazine, call the physician, and monitor vital signs. Give the next dose of fluphenazine and restrict the client to the room to decrease stimulation. Withhold the next dose of fluphenazine, administer an antipyretic agent, and increase the client’s fluid intake. Question 30 WRONG The nurse is preparing for the discharge of a client who has been hospitalized for paranoid schizophrenia. The client’s husband expresses concern over whether his wife will continue to take her daily prescribed medication. The nurse should inform him that: his concern is valid but his wife is an adult and has the right to make her own decisions. he can easily mix the medication in his wife’s food if she stops taking it. his wife can be given a long-acting medication that is administered every 1 to 4 weeks. his wife knows she must take her medication as prescribed to avoid future hospitalizations. Question 30 Explanation: Long-acting psychotropic drugs can be administered by depot injection every 1 to 4 weeks. These agents are useful for noncompliant clients because the client receives the injection at the outpatient clinic. A client has the right to refuse medication, but this issue isn’t the focus of discussion at this time. Medication should never be hidden in food or drink to trick the client into taking it; besides destroying the client’s trust, doing so would place the client at risk for Question 29 Explanation: Malignant neuroleptic syndrome is a dangerous adverse effect of neuroleptic drugs such as fluphenazine. The nurse should withhold the next dose, notify the physician, and continue to monitor vital signs. Although an antipyretic agent may be used to reduce fever, increased fluid intake is contraindicated because it may increase the client’s fluid volume further, raising blood pressure even higher. Question 28 Explanation: 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. Question 27 Explanation: Schizophrenia is best described as one of a group of psychotic reactions characterized by disturbed relationships with others and an inability to communicate and think clearly. Schizophrenic thoughts, feelings, and behavior commonly are evidenced by withdrawal, fluctuating moods, disordered thinking, and regressive tendencies. Severe mood swings and periods of low to high activity are typical of bipolar disorder. Multiple personality, sometimes confused with schizophrenia, is a dissociative personality disorder, not a psychotic illness. Many schizophrenic clients have auditory hallucinations; tactile hallucinations are more common in organic or toxic disorders

A

D

A

B

WRONG

During the initial interview, a client with schizophrenia suddenly turns to the empty chair beside him and whispers, “Now just leave. I told you to stay home. There isn’t enough work here for both of us!” What is the nurse’s best initial response? “When people are under stress, they may see things or hear things that others don’t. Is that what just happened?”

B

“I’m having a difficult time hearing you. Please look at me when you talk.” “There is no one else in the room. What are you doing?”

D

Que This relati Con “Who are you talking to? Are you hallucinating?” stion 35 Explanation: response makes the client feel that experiencing hallucinations is acceptable and promotes an open, therapeutic onship. Directing the client to look at the nurse wouldn’t address the obvious issue of the hallucination. frontational approaches, such as in options C and D, are likely to elicit an uninformative or negative response. Question 36 WRONG A client tells the nurse that the television newscaster is sending a secret message to her. The nurse suspects the client is experiencing:

A a^ delusion.

B flight of ideas.

ideas of reference. a hallucination. Question 37 WRONG The nurse formulates a nursing diagnosis of Impaired social interaction related to disorganized thinking for a client with schizotypal personality disorder. Based on this nursing diagnosis, which nursing intervention takes highest priority?

A Helping^ the^ client^ to^ participate^ in^ social^ interactions

Establishing a one-on-one relationship with the client Exploring the effects of the client’s behavior on social interactions

D

Que By e The Developing a schedule for the client’s participation in social interactions stion 37 Explanation: stablishing a one-on-one relationship, the nurse helps the client learn how to interact with people in new situations. other options are appropriate but should take place only after the nurse-client relationship is established. Question 38 WRONG A client has a history of chronic undifferentiated schizophrenia. Because she has a history of noncompliance with antipsychotic therapy, she’ll receive fluphenazine decanoate (Prolixin Decanoate) injections every 4 weeks. Before discharge, what should the nurse include in her teaching plan?

A

Asking the physician for droperidol (Inapsine) to control any extrapyramidal symptoms that occur Sitting up for a few minutes before standing to minimize orthostatic hypotension Notifying the physician if her thoughts don’t normalize within 1 week

D

Que The antic Expecting symptoms of tardive dyskinesia to occur and to be transient stion 38 Explanation: nurse should teach the client how to manage common adverse reactions, such as orthostatic hypotension and holinergic effects. Antipsychotic effects of the drug may take several weeks to appear. Droperidol increases the Question 36 Explanation: Ideas of reference refers to the mistaken belief that neutral stimuli have special meaning to the individual such as the television newscaster sending a message directly to the individual. A delusion is a false belief. Flight of ideas is a speech pattern in which the client skips from one unrelated subject to another. A hallucination is a sensory perception, such as hearing voices and seeing objects, that only the client experiences.

A

Question 39 WRONG Important teaching for women in their childbearing years who are receiving antipsychotic medications includes which of the following? Occurrence of increased libido due to medication adverse effects

B Increased incidence of dysmenorrhea while taking the drug

Continuing previous use of contraception during periods of amenorrhea Instruction that amenorrhea is irreversible Question 40 WRONG A client is admitted to the inpatient unit of the mental health center with a diagnosis of paranoid schizophrenia. He's shouting that the government of France is trying to assassinate him. Which of the following responses is most appropriate? "I think you're wrong. France is a friendly country and an ally of the United States. Their government wouldn't try to kill you. "I find it hard to believe that a foreign government or anyone else is trying to hurt you. You must feel frightened by this." "You're wrong. Nobody is trying to kill you." "A foreign government is trying to kill you? Please tell me more about it." Question 41 WRONG A client receiving haloperidol (Haldol) complains of a stiff jaw and difficulty swallowing. The nurse's first action is to: reassure the client and administer as needed lorazepam (Ativan) I.M. administer as needed dose of benztropine (Cogentin) I.M. as ordered. administer as needed dose of benztropine (Cogentin) by mouth as ordered. administer as needed dose of haloperidol (Haldol) by mouth. Question 42 WRONG A schizophrenic client with delusions tells the nurse, “There is a man wearing a red coat who’s out to get me.” The client exhibits increasing anxiety when focusing on the delusions. Which of the following would be the best response? “This subject seems to be troubling you. Let’s walk to the activity room.”

B

“Describe the man who’s out to get you. What does he look like?” “There is no reason to be afraid of that man. This hospital is very secure.”

D

“There is no need to be concerned with a man who isn’t even real.” Question 42 Explanation: Question 41 Explanation: The client is most likely suffering from muscle rigidity due to haloperidol. I.M. benztropine should be administered to prevent asphyxia or aspiration. Lorazepam treats anxiety, not extrapyramidal effects. Another dose of haloperidol would increase the severity of the reaction. Question 40 Explanation: Responses should focus on reality while acknowledging the client's feelings. Arguing with the client or denying his belief isn't therapeutic. Arguing can also inhibit development of a trusting relationship. Continuing to talk about delusions may aggravate the psychosis. Asking the client if a foreign government is trying to kill him may increase his anxiety level and can reinforce his delusions. Question 39 Explanation: Women may experience amenorrhea, which is reversible, while taking antipsychotics. Amenorrhea doesn’t indicate cessation of ovulation; therefore, the client can still become pregnant. The client should be instructed to continue contraceptive use even when experiencing amenorrhea. Dysmenorrhea isn’t an adverse effect of antipsychotics, and libido generally decreases because of the depressant effect. risk of extrapyramidal effects when given in conjunction with phenothiazines such as fluphenazine. Tardive dyskinesia is a possible adverse reaction and should be reported immediately

A

A

D

C

B

Question 47 CORRECT How soon after chlorpromazine (Thorazine) administration should the nurse expect to see a client's delusional thoughts and hallucinations eliminated

A Several^ minutes

B Several^ hours

C Several^ days

Que Alth seve Several weeks stion 47 Explanation: ough most phenothiazines produce some effects within minutes to hours, their antipsychotic effects may take ral weeks to appear. Question 48 WRONG What medication would probably be ordered for the acutely aggressive schizophrenic client?

A chlorpromazine^ (Thorazine)

haloperidol (Haldol)

C lithium^ carbonate^ (Lithonate)

amitriptyline (Elavil) Question 49 CORRECT The nurse is caring for a client with schizophrenia who experiences auditory hallucinations. The client appears to be listening to someone who isn't visible. He gestures, shouts angrily, and stops shouting in mid-sentence. Which nursing intervention is the most appropriate?

A Approach the client and touch him to get his attentio

Encourage the client to go to his room where he'll experience fewer distractions. Acknowledge that the client is hearing voices but make it clear that the nurse doesn't hear these voices.

D Ask^ the^ client^ to^ describe^ what^ the^ voices^ are^ saying.

Question 50 WRONG A schizophrenic client states, “I hear the voice of King Tut.” Which response by the nurse would be most therapeutic? “I don’t hear the voice, but I know you hear what sounds like a voice.”

B “You shouldn’t^ focus^ on^ that^ voice.”

C

“Don’t worry about the voice as long as it doesn’t belong to anyone real.” Que This “King Tut has been dead for years.” stion 50 Explanation: response states reality about the client’s hallucination. The other options are judgmental, flippant, or dismissive. Question 49 Explanation: By acknowledging that the client hears voices, the nurse conveys acceptance of the client. By letting the client know that the nurse doesn't hear the voices, the nurse avoids reinforcing the hallucination. The nurse shouldn't touch the client with schizophrenia without advance warning. The hallucinating client may believe that the touch is a threat or act of aggression and respond violently. Being alone in his room encourages the client to withdraw and may promote more hallucinations. The nurse should provide an activity to distract the client. By asking the client what the voices are saying, the nurse is reinforcing the hallucination. The nurse should focus on the client's feelings, rather than the content of the hallucination. Question 48 Explanation: Haloperidol administered I.M. or I.V. is the drug of choice for acute aggressive psychotic behavior. Chlorpromazine is also an antipsychotic drug; however, it causes more pronounced sedation than haloperidol. Lithium carbonate is useful in bipolar or manic disorder, and amitriptyline is used for depression. Benztropine, trihexyphenidyl, or amantadine are prescribed for a client with Parkinson-type symptoms. Diphenhydramine provides rapid relief for dystonia. Propranolol relieves akathisia. Haloperidol can cause Parkinson- type symptoms.

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