Question

A client diagnosed with schizophrenia is experiencing anhedonia. Which nursing diagnosis addresses the client's problem that this symptom may generate?

Answer 1

Correct Answers:

Risk for suicide

Rationale :

💔Anhedonia is the inability to experience pleasure from normally enjoyable activities, which increases risk for hopelessness.

⚠️This profound loss of interest can lead to depression, intensifying suicidal ideation.

🧩Clients with schizophrenia and anhedonia often withdraw socially, reducing protective factors against suicidal thoughts.

🛑Therefore, the most relevant nursing diagnosis for anhedonia is risk for suicide, as it directly addresses the life-threatening outcome.

📌Core Message

The correct diagnosis is risk for suicide because anhedonia increases hopelessness and suicidal risk.

Answer 2

Correct Answers:

Check the body for lice

Rationale :

🕷️Somatic delusions can cause clients to believe they are infested, but nursing priority is to first rule out a medical cause.

🔎By checking for lice, the nurse ensures symptoms are not due to a real infestation.

⚖️This follows the principle of addressing possible physical needs before confronting delusions.

🛡️After ruling out actual infestation, the nurse can move to presenting reality and offering psychological support.

📌Core Message

Always assess for a real medical cause before treating a somatic delusion.

Answer 3

Correct Answers:

Benztropine (Cogentin)

Rationale :

💊Haloperidol can cause extrapyramidal side effects (EPS) such as akathisia, characterized by continuous restlessness.

🧩Benztropine is an anticholinergic medication used to treat EPS by restoring neurotransmitter balance.

🛡️It helps reduce muscle stiffness, tremors, and restlessness, improving client comfort.

⚕️Other antipsychotics listed do not directly treat EPS, making benztropine the most effective intervention.

📌Core Message

Benztropine is given to treat EPS such as akathisia from haloperidol.

Answer 4

Correct Answers:

Notify the client's physician, document the incident, and review elopement precautions

Rationale :

🚨When a client elopes, the nurse must prioritize safety and proper legal documentation.

📝Notifying the physician ensures the treatment team is aware of the situation.

🔒Reviewing precautions helps prevent future elopement incidents.

⚖️Sending staff after the client or discharging without process would violate policy and safety protocols.

📌Core Message

Correct response is to notify, document, and review precautions after elopement.

Answer 5

Correct Answers:

Maintain contact with the client and assure the client that seclusion is a way to maintain safety

Rationale :

🛡️Seclusion is a restrictive intervention used only for safety, not punishment.

🤝Maintaining therapeutic contact reassures the client that the goal is protection.

💬Providing ongoing support and reassurance helps decrease fear and agitation.

⚖️Avoiding the client or focusing on teaching during crisis does not meet the immediate safety need.

📌Core Message

In seclusion, priority is to maintain contact and emphasize safety.

Answer 6

Correct Answers:

The client has been displaying signs and symptoms for 6 months

Rationale :

📅A diagnosis of schizophrenia requires continuous signs and symptoms for at least 6 months.

🔎Symptoms include hallucinations, delusions, and disorganized behavior.

🧩Other options (autism, medical condition, or substance use) represent differential diagnoses.

⚖️The duration criterion is essential in confirming schizophrenia versus other disorders.

📌Core Message

Schizophrenia requires symptoms lasting at least 6 months.

Answer 7

Correct Answers:

Hearing voices saying, "Go kill yourself."

Rationale :

🔊Command hallucinations involve voices directing the client to perform specific actions.

⚠️These commands often include harmful or dangerous behaviors like self-harm.

🛡️Such hallucinations are highly risky, requiring immediate safety interventions.

💡Unlike visual or misinterpretations, commands are distinct because they give orders.

📌Core Message

Command hallucinations involve voices giving harmful orders.

Answer 8

Correct Answers:

"Discontinue clozapine (Clozaril)."

Rationale :

⚠️Clozapine carries risk of agranulocytosis, a life-threatening drop in WBC/ANC.

📉A WBC of 2000 and ANC of 1000 indicate severe suppression.

🛑The drug must be discontinued immediately to prevent fatal infection.

⚕️Continuing or increasing the dose would worsen hematologic toxicity.

📌Core Message

Clozapine must be stopped if WBC/ANC are critically low.

Answer 9

Correct Answers:

Making observations

Rationale :

👀The nurse is describing behavior without judgment, which is making observations.

💬This helps the client become aware of emotions and encourages self-expression.

🧩Unlike clarifying or defending, this technique focuses on presenting reality of client behavior.

⚖️This approach supports therapeutic communication by fostering insight.

📌Core Message

The nurse used making observations by identifying behavior.

Answer 10

Correct Answers:

Inappropriate affect

Rationale :

😢Inappropriate affect occurs when a client’s emotional expression does not match the situation.

🙂Smiling while discussing grief demonstrates a mismatch of mood and expression.

🧩Other types of affect (restricted, broad, blunted) involve degree of emotional expression, not mismatch.

⚕️Recognizing inappropriate affect helps in accurate mental status assessment.

📌Core Message

Inappropriate affect is when emotional display mismatches the situation.

Mental Health Nursing ID-1190917 Exam-1

No.

1 :
A client diagnosed with schizophrenia is experiencing anhedonia. Which nursing diagnosis addresses the client's problem that this symptom may generate?

2 :
A client diagnosed with schizophrenia is seen in the mental health clinic complaining of insects infesting arms and legs. Which intervention should the nurse implement first?

3 :
A client has a history of schizophrenia, controlled by haloperidol (Haldol). During an assessment, the nurse notes continuous restlessness. Which medication would the nurse expect the physician to prescribe for this client?

4 :
A client has been involuntarily committed to a psychiatric unit. During the delivery of the evening dinner trays, the client escapes from the unit and the hospital. Which nursing intervention is appropriate in this situation?

5 :
A client has been placed in seclusion because the client has been deemed a danger to others. Which is the priority nursing intervention for this client on seclusion?

6 :
A client is brought to the emergency department after being found wandering the streets and talking to unseen others. Which situation is further evidence of a diagnosis of schizophrenia for this client?

7 :
A client is hearing command hallucinations. Which of the following may the client be experiencing?

8 :
A client is prescribed clozapine (Clozaril) 35 mg qd. Lab results reveal: RBC 4.7 million/mcL, Hct 48%, WBC 2000/mcL, and ANC 1000/pL. Which would the nurse expect the physician to order?

9 :
A client is restless. His face is flushed and he makes sarcastic remarks to other clients. The nurse responds by saying, "You look angry." The nurse is using which communication technique?

10 :
A client is smiling while talking about the recent death of his/her pet. The nurse understands that the client is exhibiting:

Mental Health Nursing ID-1190917 Exam-1

No.

1 : A client diagnosed with schizophrenia is experiencing anhedonia. Which nursing diagnosis addresses the client's problem that this symptom may generate?

2 : A client diagnosed with schizophrenia is seen in the mental health clinic complaining of insects infesting arms and legs. Which intervention should the nurse implement first?

3 : A client has a history of schizophrenia, controlled by haloperidol (Haldol). During an assessment, the nurse notes continuous restlessness. Which medication would the nurse expect the physician to prescribe for this client?

4 : A client has been involuntarily committed to a psychiatric unit. During the delivery of the evening dinner trays, the client escapes from the unit and the hospital. Which nursing intervention is appropriate in this situation?

5 : A client has been placed in seclusion because the client has been deemed a danger to others. Which is the priority nursing intervention for this client on seclusion?

6 : A client is brought to the emergency department after being found wandering the streets and talking to unseen others. Which situation is further evidence of a diagnosis of schizophrenia for this client?

7 : A client is hearing command hallucinations. Which of the following may the client be experiencing?

8 : A client is prescribed clozapine (Clozaril) 35 mg qd. Lab results reveal: RBC 4.7 million/mcL, Hct 48%, WBC 2000/mcL, and ANC 1000/pL. Which would the nurse expect the physician to order?

9 : A client is restless. His face is flushed and he makes sarcastic remarks to other clients. The nurse responds by saying, "You look angry." The nurse is using which communication technique?

10 : A client is smiling while talking about the recent death of his/her pet. The nurse understands that the client is exhibiting:

1 :
A client diagnosed with schizophrenia is experiencing anhedonia. Which nursing diagnosis addresses the client's problem that this symptom may generate?

2 :
A client diagnosed with schizophrenia is seen in the mental health clinic complaining of insects infesting arms and legs. Which intervention should the nurse implement first?

3 :
A client has a history of schizophrenia, controlled by haloperidol (Haldol). During an assessment, the nurse notes continuous restlessness. Which medication would the nurse expect the physician to prescribe for this client?

4 :
A client has been involuntarily committed to a psychiatric unit. During the delivery of the evening dinner trays, the client escapes from the unit and the hospital. Which nursing intervention is appropriate in this situation?

5 :
A client has been placed in seclusion because the client has been deemed a danger to others. Which is the priority nursing intervention for this client on seclusion?

6 :
A client is brought to the emergency department after being found wandering the streets and talking to unseen others. Which situation is further evidence of a diagnosis of schizophrenia for this client?

7 :
A client is hearing command hallucinations. Which of the following may the client be experiencing?

8 :
A client is prescribed clozapine (Clozaril) 35 mg qd. Lab results reveal: RBC 4.7 million/mcL, Hct 48%, WBC 2000/mcL, and ANC 1000/pL. Which would the nurse expect the physician to order?

9 :
A client is restless. His face is flushed and he makes sarcastic remarks to other clients. The nurse responds by saying, "You look angry." The nurse is using which communication technique?

10 :
A client is smiling while talking about the recent death of his/her pet. The nurse understands that the client is exhibiting: