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A nurse is reviewing the DSM-5 diagnostic criteria for schizophrenia. Which of the following symptoms must be present for a client to be diagnosed with schizophrenia? (Select all that apply.)

Impaired interpersonal relationships

Inability to initiate activities

Disorganized behavior

Antisocial personality

Hallucinations

Lack of emotional expression

Answer and Explanation

Correct Answer : C,E,F

Choice A reason:

Impaired interpersonal relationships can be a consequence of schizophrenia, but it is not a specific diagnostic criterion in the DSM-5. The criteria focus on more direct symptoms of the disorder.

Choice B reason:

Inability to initiate activities may be related to negative symptoms of schizophrenia, such as avolition, but it is not explicitly listed as a diagnostic criterion in the DSM-5. The criteria include more specific symptoms like disorganized behavior and hallucinations.

Choice C reason:

Disorganized behavior is one of the core symptoms of schizophrenia according to the DSM-5. It includes behaviors that are inappropriate or not goal-directed, reflecting a disruption in normal functioning.

Choice D reason:

Antisocial personality is a separate diagnosis and not a criterion for schizophrenia. Schizophrenia and antisocial personality disorder are distinct conditions with different diagnostic criteria.

Choice E reason:

Hallucinations are a key symptom of schizophrenia. They involve perceiving things that are not present, such as hearing voices or seeing things that others do not see. Hallucinations are one of the primary positive symptoms of schizophrenia.

Choice F reason:

Lack of emotional expression, also known as affective flattening, is a negative symptom of schizophrenia. It involves a reduced ability to express emotions and is a significant criterion in the diagnosis of schizophrenia.

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Correct Answer is C

Explanation

Choice A reason:

Anticipating removing the restraints every 4 hours is not the best practice. Restraints should be checked frequently, typically every 2 hours, to assess the client’s circulation, skin integrity, and need for continued restraint. The goal is to use restraints for the shortest duration possible.

Choice B reason:

Securing the restraints to the lowest bar of the side rail is incorrect. Restraints should be secured to a part of the bed frame that moves with the client, not to the side rail, to prevent injury and ensure the client’s safety.

Choice C reason:

Securing the restraints using a quick-release tie is the correct action. This ensures that the restraints can be quickly and easily removed in case of an emergency, prioritizing the client’s safety.

Choice D reason:

Ensuring four fingers fit under the restraints to prevent constriction is not accurate. The correct practice is to ensure that two fingers can fit between the restraint and the client’s skin to prevent constriction and ensure proper circulation.

A. A lot of clients behave that way, but you cannot take it personally. B. Have you tried to establish a therapeutic relationship with the clients? C. Do you want me to assign another nurse? D. Clients often behave that way when they are in pain.

Correct Answer is B

Explanation

Choice A reason:
While this response acknowledges the nurse’s feelings, it does not provide a constructive solution or address the underlying issue. It may come across as dismissive rather than supportive.

Choice B reason:
Establishing a therapeutic relationship is fundamental to effective nursing care. This response encourages the nurse to build rapport and trust with the clients, which can improve their engagement and cooperation in their care. It is a proactive and supportive suggestion.

Choice C reason:
Offering to assign another nurse does not address the issue of building a therapeutic relationship and may not be feasible. It also does not help the nurse develop skills to improve client interactions.

Choice D reason:
While clients in pain may exhibit disinterest, this response does not address the broader issue of establishing a therapeutic relationship. It focuses on a specific cause rather than providing a general strategy for improving client engagement.

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A nurse is reviewing the DSM-5 diagnostic criteria for schizophrenia. Which of the following symptoms must be present for a client to be diagnosed with schizophrenia? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

The charge nurse is talking with another nurse who states, “I feel like my clients have no interest in their care and do not care that I am trying to help.” Which response should the charge nurse make?

Correct Answer is B

Explanation

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