Based on the information in the nurse's note, what assessment of the client is a priority? Use the chart exhibit to answer this question.
Chart: Name: James Justi, Age: 25. Diagnosis of schizoaffective disorder admitted from ER. Client with flat affect, pulled cover up to neck, curled up in bed, refused to speak with nurse. Family states client has been acting strange and reported hearing "voices" that no one else hears. Client refusing to leave the house, unable to take care of self-care needs, appears withdrawn and depressed. Unable to get the client to take a bath in 4 days.
Correct Answer Rationale: The priority assessment is "Assessing what the voices are saying to the client." This is important because auditory hallucinations, such as hearing voices, are a key symptom of schizoaffective disorder and can be linked to the client's mental state. Understanding the content of the hallucinations is crucial to assess for potential safety risks.
Question 2
A 28-year-old client with schizoaffective disorder is admitted to the psychiatric unit. The client is displaying symptoms of severe depression, including lack of interest in activities, poor grooming, and excessive sleeping. The nurse notes that the client has not eaten in 24 hours and appears to have lost weight. What assessment is the priority?
Chart: Name: Sarah Manning, Age: 28. Diagnosis of schizoaffective disorder admitted from outpatient clinic. Client presents with poor hygiene, disheveled appearance, and appears withdrawn. Family member reports client has been isolating, not engaging in activities, has refused meals, and has been sleeping excessively. Client reports feeling "empty" and has been tearful.
Correct Answer Rationale: The client is exhibiting signs of severe depression, withdrawal, and poor appetite, which are often associated with an increased risk of suicide. It is essential to assess the client for any suicidal thoughts or plans to ensure immediate safety.
Question 3
A 40-year-old client with schizoaffective disorder is being evaluated for medication management. The client is currently experiencing symptoms of mania, including excessive energy, rapid speech, and impulsive behaviors. The nurse is planning to assess the client's medication adherence. What question would be most important to ask the client?
Chart: Name: John Walker, Age: 40, Allergies: Penicillin. Diagnosis of schizoaffective disorder, currently in a manic episode. Client exhibits rapid speech, impulsive behavior, elevated mood, spending large amounts of money, making impulsive decisions. Client denies any recent medication adjustments.
Correct Answer Rationale: In manic episodes, clients with schizoaffective disorder may be at risk for medication nonadherence, either due to impulsivity or a belief that they do not need the medications. Assessing adherence is crucial to understanding whether the symptoms are exacerbated by nonadherence.
Question 4
The nurse in the emergency department calls admission report to the unit for a client with schizoaffective disorder who is experiencing command hallucinations and is restless and agitated. What plan should the nurse have for the client's arrival on the unit?
Correct Answer Rationale: Providing a safe outlet for physical energy, such as a quiet space or supervised physical activity, can help reduce agitation and prevent harm. Restraints should be avoided unless absolutely necessary, and validating or forcing the client to confront hallucinations is not therapeutic.
Question 5
The nurse is caring for a client with schizoaffective disorder who has been prescribed an antipsychotic medication for the past few weeks. The client reports feeling better and says, "I feel like I can think clearly now, but I still have these voices in my head telling me to do things." What is an appropriate response by the nurse?
Correct Answer Rationale: The client's statement indicates ongoing auditory hallucinations, which can pose a safety risk depending on the nature of the commands. The nurse's priority is to assess the content of the hallucinations to determine if the client is at risk of harm.
Question 6
The nurse is caring for a client with schizoaffective disorder who has been prescribed a mood stabilizer and an antipsychotic medication. The client is showing signs of increased irritability, poor concentration, and excessive energy. What is the nurse's priority action?
Correct Answer Rationale: The client's increased irritability, poor concentration, and excessive energy could be indicative of a manic episode, which is a common feature of schizoaffective disorder. It's important to assess the client's mood and behavior to determine if an adjustment in the medication regimen is needed.
Question 7
A client on the behavioral unit is pacing the floor in the room and having an audible conversation with invisible persons. What nursing action is appropriate?
Correct Answer Rationale: The nurse should attempt to engage the client in an activity or conversation that diverts their attention away from the hallucinations, which can help reduce the client's focus on the hallucinations and decrease agitation.
Question 8
A client with schizoaffective disorder is admitted to the psychiatric unit and is exhibiting disorganized behavior. The client is incoherent in speech, is unable to complete tasks, and has difficulty maintaining hygiene. What is nurse's best approach to support the client's immediate needs?
Correct Answer Rationale: When a client with schizoaffective disorder is experiencing disorganized behavior, the priority is to support their basic needs in a calm, nonjudgmental manner. Assisting the client with hygiene provides direct support and promotes dignity, safety, and comfort during an acute episode.
Question 9
A client diagnosed with schizoaffective disorder is admitted to the behavioral health unit. The client appears anxious, stating, "I feel like everything is moving too fast. I can't keep up with the noise in my head." The nurse notes the client is talking to unseen others and pacing the room. What is the most appropriate nursing action at this time?
Correct Answer Rationale: The most appropriate nursing action is to provide a calm, quiet environment and acknowledge the client's feelings. This approach helps decrease external stimulation, supports safety, and establishes trust. Confrontation and commands to ignore the voices are typically not effective and may escalate the situation.
Question 10
When the nurse provides discharge teaching to a client who was admitted with an acute psychotic episode, what statement by the client causes the nurse to believe that teaching needs to be reinforced?
Correct Answer Rationale: The statement indicates a misunderstanding of the importance of consistent medication adherence. Clients with schizophrenia often experience symptom improvement while on medication, but discontinuing medication can lead to a relapse of symptoms.
Question 11
A client diagnosed with schizoaffective disorder is discussing discharge plans with the nurse. The nurse provides education on recognizing early warning signs of relapse. Which statement by the client requires further teaching?
Correct Answer Rationale: Waiting to see if mood swings improve on their own may delay treatment and worsen symptoms. Clients need to seek help immediately when experiencing early warning signs of relapse.
Question 12
A client with schizoaffective disorder is participating in a group therapy session and discussing their treatment plan. The nurse emphasizes the importance of medication adherence. Which statement by the client indicates the need for further education?
Correct Answer Rationale: The statement about taking medications only when hearing voices indicates a misunderstanding. Schizoaffective disorder requires consistent medication use to maintain stability and prevent relapse, even when symptoms are not present.