A nurse is caring for a client who has schizophrenia.

Nurses' Notes: Day 1 1030: A 35-year-old client who has schizophrenia is admitted.

Diagnosed 15 years ago.

Brought in by partner and states client has remained in room for the last several days and movements are delayed.

Day 1 1730: Client refuses to eat or drink.

Client appears withdrawn and does not engage in conversation.

Client has flat affect.

Does not want to go to therapy session and wants to sleep.

Client's movements are slow.

Vital Signs: Day 1 1030: Temperature 37° C (98.6° F). Heart rate 72/min.

Respiratory rate 20/min.

Blood pressure 132/38 mm Hg. Oxygen saturation: 99% on room air.

Select the "3" findings that should indicate to the nurse the client is experiencing negative symptoms related to their schizophrenia:.

Withdrawn.

Lack of energy.

Change in behavior.

Lack of motivation.

Blood pressure.

Answer and Explanation

Correct Answer : A,B,D

Choice A rationale:
Being withdrawn is a negative symptom of schizophrenia. It refers to the lack of social engagement and reduced interest in others.
Choice B rationale:
Lack of energy, or avolition, is a negative symptom of schizophrenia. It refers to a decrease in the initiation and persistence of goal-directed activities.
Choice C rationale:
Change in behavior is too broad to be considered a specific negative symptom of schizophrenia. Both positive and negative symptoms of schizophrenia can lead to changes in behavior.
Choice D rationale:
Lack of motivation, or avolition, is a negative symptom of schizophrenia. It refers to a decrease in the initiation and persistence of goal-directed activities.
Choice E rationale:
Blood pressure is not a symptom of schizophrenia. It is a physiological measurement and does not reflect the psychological symptoms of schizophrenia.

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Correct Answer is D

Explanation

Choice A rationale:
Asking direct questions about the hallucination may validate the hallucination as real in the client’s mind.
Choice B rationale:
Instructing the client to argue with the voices could potentially increase the client’s distress.
Choice C rationale:
Acting as if the hallucination is real may reinforce the client’s belief in the hallucination.
Choice D rationale:
Telling the client that the hallucination is not a part of reality can help ground the client in reality.

A. "I know you hear the voices, but I do not.”. B. "The voices are part of your illness.”. C. "How often do you hear the voices?". D. "What are the voices telling you?".

Correct Answer is D

Explanation

Choice A rationale:

While acknowledging the voices can be part of therapeutic communication, it’s not the first response a nurse should make.

Choice B rationale:

Telling the client that the voices are part of their illness can be helpful, but it’s not the first response a nurse should make.

Choice C rationale:

Asking about the frequency of the voices can be part of the assessment, but it’s not the first response a nurse should make.

Choice D rationale:

Asking what the voices are saying can help assess if the client is experiencing command hallucinations, which could pose a safety risk.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has schizophrenia and is experiencing a hallucination. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following responses should the nurse make first?

Correct Answer is D

Explanation

A nurse is preparing to teach a client about his prescription of lithium for the treatment of bipolar disorder. Which of the following statements should the nurse include in the teaching?

A nurse is talking with a client who has schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things.”. Which of the following responses by the nurse is appropriate?.

A nurse is caring for a client who has been prescribed clozapine. Which of the following topics should the nurse prepare to discuss with the client?.

A nurse is caring for a client who has bipolar disorder and a new prescription for valproate. Which of the following instructions should the nurse give the client about the use of this medication?

A nurse in a mental health clinic is conducting a staff education session on schizophrenia. Which of the following manifestations should the nurse identify as negative symptoms? (Select all that apply.).

A nurse is reviewing laboratory results for a client and notes a serum lithium level of 1.6 mEq/L. Which of the following manifestations should the nurse expect the client to report?.

A nurse is assessing a client who has schizophrenia and is taking risperidone. Which of the following findings should the nurse expect?.