Adams4e Tif Ch17

Adams, Pharmacology for Nurse: A Pathophysiologic Approach, 4/EChapter 17Question 1Type: MCMA

The patient has been admitted to the hospital for the treatment of schizophrenia. The patient's mother says to the nurse, "This is all so confusing. How did he get this? Did I do something?" What is (are) the best response(s) of the nurse?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. "Schizophrenia is a biological brain disorder."

2. "Schizophrenia is linked to drinking alcohol during pregnancy."

3. "Research indicates that a very stressful environment causes schizophrenia."

4. "Research indicates that schizophrenia is a genetic disorder."

5. "Schizophrenia is due to too much dopamine in certain parts of the brain."

Correct Answer: 1,4,5

Rationale 1: Theories explaining the cause of schizophrenia include a genetic component, imbalances in neurotransmitters in specific areas of the brain, and overactive dopaminergic pathways in the basal nuclei. There isn't any evidence to support that schizophrenia is linked to alcohol consumption during pregnancy. A stressful environment will exacerbate the symptoms of schizophrenia, but does not cause the illness.




Adams, Pharmacology for Nurse: A Pathophysiologic Approach, 4/ECopyright 2014 by Pearson Education, Inc.


Global Rationale:

Cognitive Level: ApplyingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 17-1

Question 2Type: MCSA

The patient with schizophrenia is sitting quietly in a chair. The patient does not respond much to what is happening, and has a lack of interest in the environment. What best describes the result of the nurse's assessment?

1. The patient is most likely very depressed.

2. The patient is most likely hearing voices.

3. The patient is experiencing positive symptoms.

4. The patient is experiencing negative symptoms.

Correct Answer: 4

Rationale 1: Negative symptoms are those that subtract from normal behavior. These symptoms include a lack of interest, motivation, responsiveness, or pleasure in daily activities. Positive symptoms include hallucinations, delusions, and a disorganized thought or speech pattern. There isn't any evidence to support that the patient is hearing voices. There isn't any evidence to support that the patient is very depressed.



Rationale 4: Negative symptoms are those that subtract from normal behavior. These symptoms include a lack of interest, motivation, responsiveness, or pleasure in daily activities. Positive symptoms include hallucinations,


delusions, and a disorganized thought or speech pattern. There isn't any evidence to support that the patient is hearing voices. There isn't any evidence to support that the patient is very depressed.

Global Rationale:

Cognitive Level: ApplyingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 17-2


The physician has prescribed haloperidol (Haldol) for the patient with schizophrenia. What is the priority patient outcome?

1. The patient will consume adequate fluids and a high-fiber diet.

2. The patient will be compliant with taking the medication as prescribed.

3. The patient will report a decrease in auditory hallucinations.

4. The patient will report symptoms of restlessness.

Correct Answer: 2

Rationale 1: Medication compliance is a priority for patients with schizophrenia. Relapse of symptoms will occur without the medications. The symptom of restlessness is known as akathisia. This would be important to report, but is not the priority outcome. Adequate fluids and fiber will decrease the side effect of constipation, but this is not the priority outcome. A decrease in auditory hallucinations is an expected effect of haloperidol (Haldol), but this is not the priority outcome.



Rationale 4: Medication compliance is a priority for patients with schizophrenia. Relapse of symptoms will occur without the medications. The symptom of restlessness is known as akathisia. This would be important to report, Adams, Pharmacology for Nurse: A Pathophysiologic Approach, 4/ECopyright 2014 by Pearson Education, Inc.

but is not the priority outcome. Adequate fluids and fiber will decrease the side effect of constipation, but this is not the priority outcome. A decrease in auditory hallucinations is an expected effect of haloperidol (Haldol), but this is not the priority outcome.

Global Rationale:

Cognitive Level: ApplyingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 17-4


The nurse is managing the care of a group of patients with schizophrenia. The patients are receiving conventional antipsychotic medications. When assessing for anticholinergic side effects, which would the nurse immediately report to the physician?

1. Acute dystonia

2. Complaint of a severe headache

3. Hypertension

4. Urinary retention

Correct Answer: 4

Rationale 1: Urinary retention is an anticholinergic side effect of conventional antipsychotics. This must be reported immediately to the physician. Hypotension, not hypertension is a cardiac side effect, not an anticholinergic side effect. Headaches are not anticholinergic side effects. Acute dystonia must be reported immediately to the physician, but this is not an anticholinergic side effect.



Rationale 4: Urinary retention is an anticholinergic side effect of conventional antipsychotics. This must be reported immediately to the physician. Hypotension, not hypertension is a cardiac side effect, not an


anticholinergic side effect. Headaches are not anticholinergic side effects. Acute dystonia must be reported immediately to the physician, but this is not an anticholinergic side effect.

Global Rationale:



The patient has been receiving chlorpromazine (Thorazine) for the treatment of schizophrenia. The nurse assesses that the patient has tardive dyskinesia. What describes the result of the nurse's assessment?

1. Tremor, muscle rigidity, and a shuffling gait

2. Severe muscle spasms of the back, neck, and tongue

3. An inability to rest or relax, and restlessness

4. Unusual facial movements and lip smacking

Correct Answer: 4

Rationale 1: Tardive dyskinesia is characterized by unusual tongue and face movements such as lip smacking, and wormlike motions of the tongue. Severe muscle spasms of the back, neck, and tongue are known as acute dystonia, not tardive dyskinesia. An inability to rest or relax, and restlessness are known as akathisia, not tardive dyskinesia. Tremor, muscle rigidity, and a shuffling gait are known as Parkinsonism, not tardive dyskinesia.





Global Rationale:



The patient is receiving risperidone (Risperdal). During morning assessment, the nurse notes that the patient has a temperature of 102 degrees F. What is the priority nursing intervention?

1. Contact the physician, as this could be a symptom of neuroleptic malignant syndrome.

2. Contact the physician, as this could be a symptom of an acute urinary infection.

3. Contact the physician, as this could be a symptom of a bacterial pneumonia.

4. Contact the physician, as this could be a symptom of extrapyramidal side effects.

Correct Answer: 1

Rationale 1: Neuroleptic malignant syndrome includes symptoms of elevated temperature, unstable blood pressure, profuse sweating, dyspnea, muscle rigidity, and incontinence. Patients with acute urinary infections do run elevated temperatures; however, when the patient is receiving an antipsychotic drug and runs an elevated temperature, neuroleptic malignant syndrome must always be suspected. Patients with bacterial pneumonias do run elevated temperatures; however, when the patient is receiving an antipsychotic drug and runs an elevated temperature, neuroleptic malignant syndrome must always be suspected. An elevated temperature is not an extrapyramidal side effect.


Rationale 3: Neuroleptic malignant syndrome includes symptoms of elevated temperature, unstable blood pressure, profuse sweating, dyspnea, muscle rigidity, and incontinence. Patients with acute urinary infections do run elevated temperatures; however, when the patient is receiving an antipsychotic drug and runs an elevated temperature, neuroleptic malignant syndrome must always be suspected. Patients with bacterial pneumonias do run elevated temperatures; however, when the patient is receiving an antipsychotic drug and runs an elevated temperature, neuroleptic malignant syndrome must always be suspected. An elevated temperature is not an extrapyramidal side effect.Adams, Pharmacology for Nurse: A Pathophysiologic Approach, 4/ECopyright 2014 by Pearson Education, Inc.


Global Rationale:



The patient is receiving clozaril (Clozapine) for the treatment of schizophrenia. The nurse evaluates the effectiveness of this medication when the patient makes which statement?

1. "I will start going to group therapy."

2. "I think I am ready for discharge, as I feel better."

3. "I am not hearing the voices anymore."

4. "I promise not to skip breakfast anymore."

Correct Answer: 3

Rationale 1: Therapeutic effects of clozapine (Clozaril) include remission of a range of psychotic symptoms to include delusions, paranoia, auditory hallucinations, and irrational behavior. A patient stating he feels better and is ready for discharge does not indicate the remission of any psychotic symptoms. A patient stating he will go to group therapy does not indicate the remission of any psychotic symptoms. A patient stating he will not skip breakfast does not indicate the remission of any psychotic symptoms.


Rationale 3: Therapeutic effects of clozapine (Clozaril) include remission of a range of psychotic symptoms to include delusions, paranoia, auditory hallucinations, and irrational behavior. A patient stating he feels better and is ready for discharge does not indicate the remission of any psychotic symptoms. A patient stating he will go to Adams, Pharmacology for Nurse: A Pathophysiologic Approach, 4/ECopyright 2014 by Pearson Education, Inc.

group therapy does not indicate the remission of any psychotic symptoms. A patient stating he will not skip breakfast does not indicate the remission of any psychotic symptoms.


Global Rationale:

Cognitive Level: ApplyingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: EvaluationLearning Outcome: 17-9


The nurse has completed medication education with the patient who is receiving clozapine (Clozaril). The nurse evaluates that the education has been effective when the patient makes which statement?

1. "I must call my doctor if I start to have a lot of nightmares."

2. "I must have my blood work done while taking this medication."

3. "I must call my doctor if I start to lose a lot of weight."

4. "I must call my doctor if I notice any unusual bruising."

Correct Answer: 2

Rationale 1: Agranulocytosis can be a life-threatening side effect of clozapine (Clozaril), which may also suppress bone marrow, and lower infection-fighting ability. It is very important, therefore, that the patient have regular blood work done while on this medication. Bruising is not a side effect of clozapine (Clozaril). Weight gain, not weight loss, is a serious side effect of clozapine (Clozaril). Nightmares are not a side effect of clozapine (Clozaril).


Rationale 3: Agranulocytosis can be a life-threatening side effect of clozapine (Clozaril), which may also suppress bone marrow, and lower infection-fighting ability. It is very important, therefore, that the patient have Adams, Pharmacology for Nurse: A Pathophysiologic Approach, 4/ECopyright 2014 by Pearson Education, Inc.

regular blood work done while on this medication. Bruising is not a side effect of clozapine (Clozaril). Weight gain, not weight loss, is a serious side effect of clozapine (Clozaril). Nightmares are not a side effect of clozapine (Clozaril).


Global Rationale:



The patient is receiving clozapine (Clozaril). What is a priority outcome for this patient?

1. The patient reports any narrowing of the field of vision.

2. The patient reports any joint pain or swelling.

3. The patient reports any signs of a sore throat or an infection.

4. The patient reports any yellowish halos around lights.

Correct Answer: 3

Rationale 1: Signs of a sore throat or an infection could indicate agranulocytosis, which is a life-threatening side effect of clozapine (Clozaril). Yellowish halos around lights are not a side effect of clozapine (Clozaril). Joint pain or swelling is not a side effect of clozapine (Clozaril). Narrowing of the field of vision is not a side effect of clozapine (Clozaril).


Rationale 3: Signs of a sore throat or an infection could indicate agranulocytosis, which is a life-threatening side effect of clozapine (Clozaril). Yellowish halos around lights are not a side effect of clozapine (Clozaril). Joint pain or swelling is not a side effect of clozapine (Clozaril). Narrowing of the field of vision is not a side effect of clozapine (Clozaril).Adams, Pharmacology for Nurse: A Pathophysiologic Approach, 4/ECopyright 2014 by Pearson Education, Inc.


Global Rationale:

Cognitive Level: ApplyingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 17-7


For any patient receiving clozapine (Clozaril), which laboratory result should be reported to the physician?

1. Red blood cell (RBC) of 3.8 million cells/mL

2. Red blood cell (RBC) of 5.0 million cells/mL

3. White blood cell (WBC) of 3,800 cells/mcl

4. White blood cell (WBC) of 12,000 cells/mcl

Correct Answer: 3

Rationale 1: The normal white blood cell (WBC) count is 4,500–10,500 cells/mcl. A lower count indicates agranulocytosis, which is a life-threatening side effect of clozapine (Clozaril). A red blood cell (RBC) of 5.0 million cells/mL is a normal red blood cell (RBC) count. A white blood cell (WBC) of 12,000 cells/mcl is an elevated white blood cell (WBC) count and could indicate an infection, but it is not a side effect of clozapine (Clozaril). A red blood cell (RBC) of 3.8 million cells/mL is a low range of red blood cells (RBCs) and could indicate anemia, but it is not a side effect of clozapine (Clozaril).


Rationale 3: The normal white blood cell (WBC) count is 4,500–10,500 cells/mcl. A lower count indicates agranulocytosis, which is a life-threatening side effect of clozapine (Clozaril). A red blood cell (RBC) of 5.0 million cells/mL is a normal red blood cell (RBC) count. A white blood cell (WBC) of 12,000 cells/mcl is an elevated white blood cell (WBC) count and could indicate an infection, but it is not a side effect of clozapine


(Clozaril). A red blood cell (RBC) of 3.8 million cells/mL is a low range of red blood cells (RBCs) and could indicate anemia, but it is not a side effect of clozapine (Clozaril).


Global Rationale:



The nurse has completed diet education for a group of patients who are receiving antipsychotic medications. If the medication education has been effective, patients will eliminate what choice from their menu selection?

1. Meats with a high-fat content

2. Beverages with caffeine

3. Refined breads and desserts

4. Shellfish and peanuts

Correct Answer: 2

Rationale 1: The use of caffeine-containing substances will decrease the effect of antipsychotic medications. Although unhealthy, high-fat meats do not affect the action of antipsychotic medications. Although unhealthy, refined breads and desserts do not affect the action of antipsychotic medications. Many individuals are allergic to shellfish and peanuts, but they do not affect the action of antipsychotic medications.


Rationale 3: The use of caffeine-containing substances will decrease the effect of antipsychotic medications. Although unhealthy, high-fat meats do not affect the action of antipsychotic medications. Although unhealthy,


refined breads and desserts do not affect the action of antipsychotic medications. Many individuals are allergic to shellfish and peanuts, but they do not affect the action of antipsychotic medications.


Global Rationale:



The patient is receiving antipsychotic medications and tells the nurse he has not had a bowel movement for 2 days. What is the best initial action of the nurse?

1. Hold the medication until the patient has a bowel movement.

2. Have the patient drink prune juice and additional fluids.

3. Contact the physician for an order for a Fleet Enema.

4. Contact the physician for an order for a stool softener.

Correct Answer: 2

Rationale 1: Constipation is a common side effect of antipsychotic medications. The best approach is to have the patient increase dietary fiber and fluids, and to exercise to prevent constipation. Contacting the physician for an order for a Fleet Enema is premature; the patient should initially increase dietary fiber, fluids, and exercise to prevent constipation. Contacting the physician for an order for a stool softener is premature; the patient should initially increase dietary fiber, fluids, and exercise to prevent constipation. Antipsychotic medications should not be held because of constipation.





Global Rationale:



The patient who is receiving antipsychotic medication complains of having a dry mouth. The patient refused the morning dose of the medication. What is the best response by the nurse?

1. "Why are you refusing the medicine?"

2. "I can give you benztropine (Cogentin) for your dry mouth."

3. "I will let your doctor know about your dry mouth."

4. "A dry mouth is common, but drinking more water will help."

Correct Answer: 4

Rationale 1: The symptom of dry mouth is very common with antipsychotic medications. The best approach is to have the patient suck on sugarless candy, chew gum, or have frequent drinks of water. Benztropine (Cogentin) is indicated for extrapyramidal side effects, not for a dry mouth. Asking the patient why he is refusing his medication is an inappropriate question, as the nurse knows the patient has been complaining of a dry mouth. Dry mouth is a common side effect treated by nursing interventions, not physician's orders.

Rationale 2: The symptom of dry mouth is very common with antipsychotic medications. The best approach is to have the patient suck on sugarless candy, chew gum, or have frequent drinks of water. Benztropine (Cogentin) is indicated for extrapyramidal side effects, not for a dry mouth. Asking the patient why he is refusing his Adams, Pharmacology for Nurse: A Pathophysiologic Approach, 4/ECopyright 2014 by Pearson Education, Inc.

medication is an inappropriate question, as the nurse knows the patient has been complaining of a dry mouth. Dry mouth is a common side effect treated by nursing interventions, not physician's orders.



Global Rationale:



The patient receives quetiapine (Seroquel) and asks the nurse how the medication works. What is the best response by the nurse?

1. "Quetiapine (Seroquel) decreases norepinephrine in your brain and that decreases your auditory hallucinations."

2. "Quetiapine (Seroquel) increases norepinephrine in your brain and that decreases your feelings of depression."

3. "Quetiapine (Seroquel) decreases dopamine in your brain and that decreases your symptoms."

4. "Quetiapine (Seroquel) increases dopamine in your brain and that helps you to think more clearly."

Correct Answer: 3

Rationale 1: Quetiapine (Seroquel) acts by interfering with the binding of dopamine to its receptors in the brain. Quetiapine (Seroquel) does not increase dopamine in the brain. Quetiapine (Seroquel) does not decrease norepinephrine in the brain. Quetiapine (Seroquel) does not increase norepinephrine in the brain.





Global Rationale:



Symptoms of schizophrenia are thought to be associated with which receptor sites?

1. Dopamine type 2

2. Adrenergic

3. Beta 2

4. Cholinergic

Correct Answer: 1

Rationale 1: Although other receptor sites can be involved, it appears that dopamine type 2 receptors are the most responsible.




Global Rationale:

Cognitive Level: RememberingClient Need: Physiological IntegrityAdams, Pharmacology for Nurse: A Pathophysiologic Approach, 4/ECopyright 2014 by Pearson Education, Inc.

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 17-1


A patient with a psychiatric history is communicating using made-up words, and indicates he doesn’t care about anything. This patient would most likely be

1. demonstrating symptoms of depression.

2. demonstrating positive symptoms of schizophrenia.

3. demonstrating negative symptoms of schizophrenia.

4. demonstrating symptoms of bipolar disorder.

Correct Answer: 2

Rationale 1: The use of made-up words and detachment from life most likely indicate he is demonstrating the positive symptoms of schizophrenia.




Global Rationale:

Cognitive Level: UnderstandingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: DiagnosisLearning Outcome: 17-2


Which of the following drugs would be indicated for a schizophrenic who needs management of both positive and negative symptoms?


1. Thioridazine HCL (Mellaril)

2. Haloperidol (Haldol)

3. Clozapine (Clozaril)

4. Chlorpromazine (Thorazine)

Correct Answer: 3

Rationale 1: Clozaril is an atypical antipsychotic indicated for positive and negative symptoms of schizophrenia. Conventional antipsychotic agents (phenothiazines and phenothiazine-like drugs) are indicated for positive symptoms.




Global Rationale:

Cognitive Level: UnderstandingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 17-3


The relapse rate for psychotic patients who are not compliant and discontinue their medications is

1. 60–80%.

2. 50–70%.

3. 30–40%.

4. 20–50%.


Correct Answer: 1

Rationale 1: The relapse rate for psychotic patients who are not compliant and discontinue their medications is 60 to 80%.




Global Rationale:

Cognitive Level: RememberingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 17-4


An elderly female psychotic patient has been taking haloperidol (Haldol) for 1 week. The patient has been making wormlike movements with her tongue. The nurse identifies this to most likely be

1. an adverse effect likely caused by the medication, known as tardive dyskinesia.

2. a normal reaction to the medication that will likely go away in a week or two.

3. a sign that the patient has not been taking the medication.

4. a sign of the patient's underlying psychosis, indicating that the medication is not effective.

Correct Answer: 1

Rationale 1: Elderly female patients on Haldol have a higher incidence of tardive dyskinesia (an adverse effect). Tardive dyskinesia is characterized by wormlike movements of the tongue.





Global Rationale:

Cognitive Level: UnderstandingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 17-5 and 17-6


A patient experiencing an extrapyramidal adverse effect is not able to relax. This is known as

1. dystonia.

2. tardive dyskinesia.

3. akathisia.

4. Parkinsonism.

Correct Answer: 3

Rationale 1: The inability to relax is akathisia.




Global Rationale:

Cognitive Level: RememberingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: DiagnosisLearning Outcome: 17-6



Which of the following would be the most appropriate action while treating a patient who overdosed on risperidone (Risperdal) 20 minutes ago?

1. Administer a CNS depressant.

2. Administer an anticholinergic.

3. Administer activated charcoal.

4. Symptom management is the only indicated treatment.

Correct Answer: 3

Rationale 1: Activated charcoal will bind the Risperdal that has not been absorbed and prevent absorption into the bloodstream. Symptom management might be warranted, but given that the overdose occurred only 20 minutes ago, charcoal likely will be effective, and should be used. Anticholinergic agents and CNS depressants likely will worsen symptoms.




Global Rationale:

Cognitive Level: UnderstandingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 17-7


A patient who has been treated with antipsychotic agents for schizophrenia has an elevated blood pressure, dyspnea, and an extremely high temperature. This condition is known as


1. akathisia.

2. extrapyramidal side effects.

3. acute dystonias.

4. neuroleptic malignant syndrome.

Correct Answer: 4

Rationale 1: The condition that causes an elevated blood pressure, dyspnea, and high temperature is neuroleptic malignant syndrome.




Global Rationale:

Cognitive Level: RememberingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 17-9

Question 23Type: MCMA

The nurse suspects a patient is demonstrating negative symptoms of schizophrenia and will be a challenge to treat because of which barriers?



1. The patient feels that the symptoms are normal.

2. Family members feel the patient is going through a period of depression.

3. The patient is suspicious of the motives of the health care provider.

4. Family members have labeled the patient as lazy.Adams, Pharmacology for Nurse: A Pathophysiologic Approach, 4/ECopyright 2014 by Pearson Education, Inc.

5. The patient is indifferent to obtaining help.


Rationale 1: Patients with a psychosis rather than the negative symptoms of schizophrenia are often unaware that their bizarre behavior is not normal.

Rationale 2: Negative symptoms of schizophrenia are often mistaken for depression.

Rationale 3: Suspicion that someone is trying to do harm is characteristic of delusions.

Rationale 4: Negative symptoms of schizophrenia are often mistaken for laziness.

Rationale 5: Negative symptoms are characteristic of the indifferent personality typical of many patients with schizophrenia.

Global Rationale:

Cognitive Level: AnalyzingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 17-2


The nurse is performing the initial assessment on a patient admitted to the psychiatric unit. The patient hears voices saying to cut the patient's arms with razor blades until they bleed. The nurse should assess for



1. family history of first-degree relative with schizophrenia.

2. use of illegal substances.

3. recent episodes of anxiety.

4. fFamily history of heart disease.

5. hHistory of a dysfunctional family.



Rationale 1: A person has a 5Â?10 times greater risk of getting schizophrenia if a first-degree relative has the disorder.

Rationale 2: Use of drugs such as cocaine can produce hallucinations or paranoia.

Rationale 3: A history of anxiety has no connection to the development of schizophrenia.

Rationale 4: A family history of heart disease has no connection to the development of schizophrenia.

Rationale 5: Family dynamics can affect coping skills, which can influence the onset of schizophrenia.

Global Rationale:

Cognitive Level: ApplyingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 17-3


A patient with a history of suicidal behavior with schizophrenia stopped taking clozapine (Clozaril) after 4 weeks of therapy. The patient is currently experiencing a return of hallucinations. What might the nurse assess when determining the reason the patient stopped taking the medication?



1. Feeling sedated all the time

2. Significant weight gain

3. Agitation

4. Fatigue and headache

5. Lack of desire to consume alcohol

Correct Answer: 1,2,3,4

Rationale 1: Patients do not like the side effect of being sedated all the time.

Rationale 2: Substantial weight gain has been reported in some patients taking this medication. This is a reason some stop taking the medication.


Rationale 3: Agitation may be an extrapyramidal symptom of treatment with this medication and is an unwanted adverse effect.

Rationale 4: Fatigue and headache are possible side effects of this medication.

Rationale 5: The desire to drink alcohol would be a reason for the patient to stop taking this medication.

Global Rationale:

Cognitive Level: ApplyingClient Need: Physiological IntegrityClient Need Sub: Pharmacological and Parenteral TherapiesNursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 17-5


The nurse is assessing a female patient who has been taking chlorpromazine for schizophrenia. What should the nurse include in this assessment?



1. Perform an eye exam and ask if there have been changes in vision.

2. Draw blood to check a lipid profile.

3. Ask the patient questions regarding amount of alcohol intake.

4. Determine the date of her last menstrual period.

5. Draw blood to check thyroid function.


Rationale 1: Chlorpromazine accumulates in the eye, and there is a risk of phototoxicity, blurred vision, dry eyes, and glaucoma.

Rationale 2: Treatment with chlorpromazine would not be a reason to check the patient's lipid levels, and there is no information given to indicate the need to check a lipid profile.

Rationale 3: It is important to assess for alcohol use, as this could cause excessive drowsiness.

Rationale 4: It is important to assess for pregnancy as this drug is Pregnancy Category C.


Rationale 5: There is no indication that antipsychotics affect thyroid function, and nothing in the scenario indicates the need to check thyroid function.

Global Rationale:

Cognitive Level: ApplyingClient Need: Physiological IntegrityClient Need Sub: Reduction of Risk PotentialNursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 17-9


A patient taking aripiprazole (Abilify) for schizophrenia is experiencing signs of hypotension with certain activities since starting this medication. What should the nurse teach the patient?



1. Avoid being outside in the heat of the day.

2. Avoid hot baths or hot showers.

3. Avoid caffeine-containing preparations.

4. Change positions slowly, especially from lying or sitting to standing.

5. Take frequent naps during the day.


Rationale 1: The patient should avoid any situation that might cause overheating, especially in hot weather, to reduce the risk of hypotension.

Rationale 2: Hot baths and hot showers should be avoided to decrease the chance of hypotension.

Rationale 3: Caffeine products are more likely to produce anxiety or palpitations.

Rationale 4: Changing positions slowly will help reduce orthostatic hypotension.

Rationale 5: Frequent naps will not affect the symptoms of hypotension.

Global Rationale:


Cognitive Level: ApplyingClient Need: Physiological IntegrityClient Need Sub: Reduction of Risk PotentialNursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 17-11


During an assessment, the nurse determines a patient is demonstrating symptoms of a psychosis. What did the nurse assess in this patient?



1. The patient says, "The servants need to be disciplined."

2. The patient says, "The voice told me to cut myself."

3. The patient laughs when asked about the health of a family member hospitalized for cancer treatment.

4. The patient asks to close the room door so "that man can't get to me."

5. The patient says, "I have not been able to get any sleep for months."

Correct Answer: 1,2,3,4

Rationale 1: This statement is an example of a grandiose delusion.

Rationale 2: This statement is an example of an auditory hallucination.

Rationale 3: During a psychotic episode, the patient's mood and affect may vary widely and be inappropriate, such as laughing at sad events.

Rationale 4: This statement is an example of a delusion in which someone is trying to harm the patient.

Rationale 5: The lack of sleep is not a symptom of psychosis.

Global Rationale:

Cognitive Level: AnalyzingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 17-1



While conducting a health history, the nurse notes that the patient is demonstrating positive signs of schizophrenia. What did the nurse assess in this patient?



1. Disorganized sentence structure

2. Kicking the nurse

3. Not responding to questions

4. Difficulty following instructions

5. Stating that God wants the patient to go home


Rationale 1: Disorganized speech is a positive symptom of schizophrenia.

Rationale 2: Combativeness is a positive symptom of schizophrenia.

Rationale 3: Lack of responsiveness is a negative symptom of schizophrenia.

Rationale 4: Difficulty following instructions is not a positive symptom of schizophrenia.

Rationale 5: A delusion is a positive symptom of schizophrenia.

Global Rationale:

Cognitive Level: ApplyingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 17-2


Adams4e Tif Ch17

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