MH 22 Schizophrenia and Schizophrenic-like Disorders

The nurse observes a client with schizophrenia sitting alone, laughing occasionally, and turning his head as if listening to another person. The nurse assesses this behavior to indicate that the client is experiencing auditory hallucinations and says,

"Are you hearing something?"

A client diagnosed with schizophrenia tells the nurse, "I hear the voice of Elvis." Which of the following is the most therapeutic response by the nurse?

"I don't hear the voice, but I know you hear what sounds like a voice."Acknowledging that the client hears what sounds like a voice states reality about the client's hallucination.

One evening, a client with schizophrenia leaves his room and begins marching in the hall. When approached by the nurse, the client says, "God says I'm supposed to guard the area." Which of the following responses would be best?

"I understand you hear a voice. You and I are the only ones in the hall, and I don't hear a voice." Acknowledging that the client hears a voice validates that the client's experience is real to him, while presenting reality.

A client with schizophrenia tells the nurse, "I'm being watched constantly by the FBI because of my job." Which response by the nurse would be most appropriate?

"It must be frightening to feel like you're always been watched." When interacting with a client who is experiencing delusions, the nurse must remember that these experiences are real for the client. Based on the client's statement, the nurse should focus on the feelings that are generated by the delusion, such as acknowledging how frightening it must be to feel like he or she is always being watched, not the delusion itself (such as by asking the client to tell the nurse more about being watched). Telling the client that he or she is not being watched, that it is all in his mind, or that he is experiencing a delusion would be inappropriate because these statements tell the person that his or her experiences are not real.

The nurse is working with a client with schizophrenia, disorganized type. It is time for the client to get up and eat breakfast. Which of the following statements by the nurse would be most effective in helping the client prepare for breakfast?

"It's time to put your dress on now." The client needs clear direction, with tasks broken into small steps, to begin to participate in her own self-care.

A client with schizophrenia is prescribed clozapine because other prescribed medications have been ineffective. After teaching the client and family about the drug, the nurse determines that the teaching was successful when they state which of the following?

"We'll need to make sure that he has his blood count checked at least weekly."

A client with schizophrenia is reluctant to take his prescribed oral medication. The most therapeutic response by the nurse to this refusal is,

"What is it about the medicine that you don't like?" Asking the client why he doesn't like his medication explores the client's reason for refusal, which is the first step in resolving the issue.

The nurse enters the room of a client with schizophrenia the day after he has been admitted to an inpatient setting and says, "I would like to spend some time talking with you." The client stares straight ahead and remains silent. The best response by the nurse would be,

"You don't need to talk right now. I'll just sit here for a few minutes."

When preparing to educate a client regarding a newly prescribed antipsychotic medication, the nurse (Select all that apply.)

1 Encourages the use of sugar-free gum to help manage dry mouth 2 Suggests methods to minimize the potential for weight gain 3 Identifies lifestyle adjustments that the resulting lethargy may require 4 Advises the client to discuss any concerns regarding sexual dysfunction I, SEA

List the Negative Symptoms of Schizophrenia

1 diminuation or loss of normal functions 2 anergia which is a lack of energy 3 anhedonia which is a loss of pleasure or interest 4 emotional withdrawal 5 poor eye contact that is avoidant 6 blunted affect or affective flattening 7 avolition which is being passive, apathetic, or socially withdrawn 8 difficulty in abstract thinking 9 alogia which is a lack of spontaneity and flow of conversation 10 dysfunctional relationship with others 11 ambivalence

A client is considered to have an ultrahigh risk for the development of schizophrenia when the assessment process identifies

A sibling who experiences visual hallucinations. Researchers have recently identified three patient groups considered to be at "ultrahigh risk" for the development of schizophrenia. One of these is a family history of psychosis, which would include a sibling who experiences visual hallucinations.

The nurse is caring for a client who has been taking clozapine (Clozaril) for 2 weeks. The client tells the nurse, "My throat is sore, and I feel weak." The nurse assesses the client's vital signs and finds that the client has a fever. The nurse notifies the physician, expecting an order to obtain which laboratory test?

A white blood cell count. Clients who are taking clozapine are at risk for developing agranulocytosis; therefore, they should have their white blood cells and granulocytes monitored while on this medication. An immediate evaluation of blood cell status is necessary when symptoms of infection are present.

Explain Bleuler's list of A words

Affective disturbance, one of Bleuler's 4 A's, refers to the person's inability to show appropriate emotional responses. Autistic thinking, another of Bleuler's 4 A's, is a thought process in which the individual is unable to relate to others or to the environment. A third A, ambivalence, refers to contradictory or opposing emotions, attitudes, ideas, or desires for the same person, thing, or situation. And, a fourth A, association, is the inability to think logically. Agitation/irritability is not represented among Bleuler's 4 A's

A client diagnosed with schizophrenia has been prescribed clozapine (Clozaril). Which of the following is a potentially fatal side effect of this medication?

Agranulocytosis. Agranulocytosis is manifested by a failure of the bone marrow to produce adequate white blood cells. Neuroleptic malignant syndrome is a life-threatening reaction to neuroleptic medication that requires immediate treatment. Tardive dyskinesia causes involuntary movements of the tongue, mouth, facial muscles, and arm and leg muscles. Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles.

A client with schizophrenia displays poverty of speech, unchanging facial expression, and physical anergia. The nurse anticipates that the client would be prescribed which of the following?

An atypical antipsychotic. Atypical antipsychotics relieve both the positive and negative symptoms (e.g., alogia, affective blunting, avolition, anhedonia, and attentional impairment) of schizophrenia, and are less likely to cause distressing extrapyramidal side effects typically seen with traditional antipsychotics.

A client with schizophrenia walks up to the nurse with his arm outstretched and says, "My arm went away. Dog, dog, dog." How should the nurse respond?

Ask the client if he is trying to say that something is wrong with his arm. The client's illogical, symbolic, and disorganized speech often holds a message that he or she cannot express clearly. The nurse listens for themes and reflects back to the client the meaning that the nurse has deciphered. The nurse does not dismiss the client's verbal and nonverbal behaviors as meaningless or nonsense. In effect, the nurse tries to decode the communication that the client offers and validate its meaning. (less)

A college freshman is admitted to the hospital with a diagnosis of schizophrenia. Friends reported that she had been in her room for 2 days in a trance-like state, not eating or speaking to anyone. Which of the following is the highest priority for this client?

Assessing fluid intake and output Physiologic homeostasis is a priority for this client. Completing an assessment of mental status, obtaining data about college experiences, and providing adequate rest are not the highest priority

A client has been diagnosed with schizophrenia. Assessment reveals that the client lives alone. His clothing is disheveled, his hair is uncombed and matted, and his body has a strange odor. During an interview, the client's family voices a desire for the client to live with them when he is discharged. Based on the assessment findings, which nursing diagnosis would be the priority?

Bathing Self-Care Deficit related to symptoms of schizophrenia. The negative symptom of avolition may be so profound that simple activities of daily living, such as dressing, bathing, or combing hair, may not get done. Therefore, a priority nursing diagnosis for the client is Bathing/Self-Care Deficit related to the symptoms of schizophrenia.

Which of the following groups of theories is believed currently to explain the etiology of schizophrenia?

Biologic Theory is the correct answer. Schizophrenia is thought to have multiple etiologies. The overwhelming body of scientific evidence suggests that schizophrenia is a brain disease. Computed tomography scanning and magnetic resonance imaging have shown frequent enlargement of the lateral cerebral ventricles in people with schizophrenia.

Steven has been diagnosed with schizophrenia and is showing the following symptoms: immobility, rigidity, and stupor. What subtype of schizophrenia is Steven most likely suffering from?

Catatonic

The nurse notes that a client with schizophrenia sits in a chair rocking back and forth. What does the nurse recognizes this as?

Catatonic excitement. In catatonic excitement, clients may show uncontrolled and aimless motor activity. They may engage in repetitive stereotypic movements with no apparent purpose, such as rocking back and forth for hours. Clients also may manifest normal mannerisms out of context, such as grimacing for no reason.

The psychiatric nurse recognizes that a client's cultural background can contribute to the misdiagnosis of schizophrenia primarily because

Clinicians diagnosis culturally accepted beliefs as psychotic thinking. Always consider cultural differences when assessing clinical symptoms in clients with suspected psychotic disorders. Ideas that appear delusional in one culture may be acceptable in another; speaking in tongues and visual or auditory hallucinations with religious content are possible examples.

Which of the following antipsychotic medications has not been associated with tardive dyskinesia?

Clozapine (Clozaril) an atypical antipsychotic, has not been not been found to cause tardive dyskinesia.

A nursing instructor is preparing a class lecture about schizophrenia and outcomes focusing on recovery. Which of the following would the instructor include as a major goal?

Continuity of care. Outcome research has shown that schizophrenia can be successfully treated and managed. Continuity of care has been identified as a major goal of recovery for clients with schizophrenia because they are at risk for becoming lost to services if left alone after discharge.

A nurse is providing care to a client just recently diagnosed with schizophrenia during an inpatient hospital stay. Throughout the day, the nurse observes the client drinking from the water fountain quite frequently as well as carrying cans of soda and bottles of water with him wherever he goes. Upon entering the client's room, the nurse sees numerous empty cups that had been filled with fluids on his table and in the trash can. The room has an odor of urine. The nurse suspects which of the following?

Disordered water balance. Patients with schizophrenia may experience disordered water balance, manifested by consuming large amounts of fluid (4-10 L/day). They carry soda cans and water bottles with them and hoard cups and other water containers, drinking frequently from fountains, showers, and sometimes even toilets. Because of urgency and incontinence, especially at nighttime, the client's clothing and room may smell of urine. Diabetes would be manifested by changes in glucose levels and possibly weight gain.

The relationships and associations among the words used to express thoughts are markedly disturbed in clients with schizophrenia. What is this disturbance characterized by

Disorganized speech. The lack of a logical relationship between thoughts and ideas may be manifested by speech that is vague, diffuse, unfocused (loose associations), or incoherent (using words that are totally unrelated, called "word salad") or by a client's inability to get to the point (tangentiality).

The relationships and associations among the words used to express thoughts are markedly disturbed in clients with schizophrenia. What is this disturbance characterized by?

Disorganized speech. The lack of a logical relationship between thoughts and ideas may be manifested by speech that is vague, diffuse, unfocused (loose associations), or incoherent (using words that are totally unrelated, called "word salad") or by a client's inability to get to the point (tangentiality).

The most defining characteristic of undifferentiated schizophrenia is that the client

Displays both positive and negative symptomology

A physician has diagnosed a client with schizophrenia. The nurse knows that schizophrenia is characterized by which of the following?

Disturbances in affect. The Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision, defines schizophrenia as a disturbance in multiple psychological processes that affects thought content and form, perception, affect, sense of self, volition, relationship to the external world, and psychomotor behavior. Multiple personalities occur in dissociative identity disorder.

Assessment of a client with schizophrenia reveals that he is hearing voices that tell him that people are staring at him and illusions. When developing the plan of care for this client, which nursing diagnosis would be most appropriate?

Disturbed sensory perception The most appropriate nursing diagnosis would be disturbed sensory perception related to his hallucinations and illusions. Disturbed thought processes would be appropriate for delusions, confusion, and disorganized thinking. Risk for self-directed violence would be appropriate if the client verbalized that the voices were telling him to harm himself. Although ineffective coping could apply, there is nothing to support this nursing diagnosis.

Positive symptoms of schizophrenia, specifically hallucinations and delusions, are thought to be caused by hyperactivity of which neurotransmitter?

Dopamine

Schizophrenia is theorized to be caused by an excess of which neurotransmitter?

Dopamine

The nurse is caring for a client in an inpatient mental health setting. The nurse notices that when the client is conversing with other clients, he repeats what they are saying word for word. The nurse interprets this finding and documents it as which of the following?

Echolalia

A client is repeating every word that the nurse says. This would be correctly documented as which of the following?

Echolalia. Echolalia is the client's imitation or repetition of what the nurse says. A word salad is a combination of jumbled words and phrases that are disconnected or incoherent and make no sense to the listener. Clang associations are ideas that are related to one another based on sound or rhyming rather than meaning. Neologisms are words invented by the client. :

When investigating biologic theories related to schizophrenia, with of the following neuroanatomic findings would be consistent which this mental health disorder?

Enlarged lateral ventricle

Patients diagnosed with schizophrenia may experience disordered water balance that may lead to water intoxication. Which of the following may occur as a result of water intoxication?

Hyponatremia

A client with schizophrenia is admitted to the inpatient unit. He does not speak when spoken to but has been observed talking to himself on occasion. At this time, the priority goal for this client is to

Increase his reality orientation.The client needs to be oriented to reality before he can participate in other therapeutic activities.

A nurse is working with a group of clients diagnosed with schizophrenia in a community setting. Which of the following would least likely be a priority?

Managing psychosis. In the community, the priorities of care are preventing relapse, maintaining psychosocial functioning, engaging in psychoeducation, improving the quality of life, and instilling hope. Managing psychosis would be a priority for the client with acute symptoms of schizophrenia requiring emergency or inpatient focused care.

The nurse is assigned to a client with catatonic schizophrenia. Which intervention should the nurse include in the client's care plan?

Meeting all of the client's physical needs

The nurse is developing a plan for group therapy sessions for several adult clients with schizophrenia. Which of the following goals is best for this group?

Members will demonstrate better social skills. Group therapy sessions focus on social skills, concentrating on appropriate interpersonal interaction. The therapist role-plays with the client, modeling and identifying suitable social actions and responses

A nurse is preparing an in-service program for a group of psychiatric-mental health nurses about schizophrenia. Which of the following would the nurse include as a major reason for relapse?

Non-adherence to prescribed medications

Of all the theories suggesting the origin and risk factors for schizophrenia, the one that is based almost exclusively on circumstantial evidence that hypothesizes that the disorder is metabolic is the

Organic (Pathophysiologic) Theory. Of all the theories suggesting the origin and risk factors for schizophrenia, the one that is based almost exclusively on circumstantial evidence that hypothesizes that the disorder is metabolic is the organic, or pathophysiologic, theory. Environmental, or cultural, theory hypothesizes that a faulty reaction to the environment (being unable to respond selectively to numerous social stimuli) triggers schizophrenia. Psychological, or experiential, theory is based on the effects of psychological, not physiological stressors, triggering schizophrenia. The biochemical, or neurostructural, theory includes the dopamine hypothesis, which states that an excessive amount of the dopamine allows nerve impulses to bombard the mesolimbic pathway, disrupting normal cell communication and resulting in the development of hallucinations and delusions, symptoms of schizophrenia.

Which of the following constitutes a negative symptom associated with schizophrenia?

Poverty of thought. The DSM-IV-TR lists three negative characteristic symptoms of schizophrenia: alogia, affective blunting, and avolition. Other common negative symptoms include anhedonia and attentional impairment. (less)

When a client reports difficulty concentrating and problems sleeping, the nurse documents that the client is exhibiting symptomology of the schizophrenic phase referred to as

Prodomal. When a client reports difficulty concentrating and problems sleeping, the nurse documents that the client is exhibiting symptomology of the schizophrenic phase referred to as prodromal, not premorbid, progressive, or onset.

After teaching a class on antipsychotic agents, the instructor determines that the teaching was successful when the class identifies which of the following as an example of a second-generation antipsychotic agent?

Quetiapine (Seroquel) Quetiapine is an example of a second-generation antipsychotic agent. Fluphenazine, thiothixene, and chlorpromazine are examples of first-generation antipsychotic agents.

A 24-year-old man with paranoid schizophrenia is admitted to the hospital. The student nurse asks the charge nurse about what approach to take with the client, who has been exhibiting hostility and isolation. Which approach would be the most appropriate direction from the charge nurse?

Respect the client's need for personal space and avoid physical contact. A newly admitted client with paranoid schizophrenia needs a sense of trust before the nurse attempts to touch him. Using emphatic tones and veiled threats will only increase the client's anxiety and lead to increased potential for hostility and anger.

Shane is a 20-year-old man whose mother was diagnosed with schizophrenia at the age of 25. He is concerned that he may also develop the disorder. Which of the following statements regarding schizophrenia and genetics is true?

Schizophrenia has shown a strong genetic contribution.

What are the signs and symptoms of schizophrenia according to the Diagnostic and Statistical Manual of Mental Disorders?

Schizophrenia lasts at least 6 months and includes at least 1 month of two or more active-phase symptoms. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR), schizophrenia lasts at least 6 months and includes at least 1 month of two or more active-phase symptoms such as bizarre delusions, hallucinations (e.g., a running commentary of two voices conversing), disorganized speech, grossly disorganized or catatonic behavior, and negative behavior.

Which of the following would be most important for the nurse to keep in mind when establishing the nurse-patient relationship with a client with schizophrenia to promote recovery?

Short, time-limited interactions are best for the client experiencing psychosis. Engaging a client with schizophrenia takes time, and short, time-limited interactions are best for a client who is experiencing psychosis. Consistency in interactions and follow through helps to establish trust. Relationships should be built on the recovery paradigm that focuses on individualizing treatment and care that is person centered and allows for self-direction. Clients with schizophrenia are often reluctant to engage in any relationship.

When a cognitively impaired client with a history of aggressive outbursts is observed pacing and grimacing while in the dayroom, the nurse initially

Suggests that they go into the client's room. Removing the client from the milieu is the initial intervention that best addresses the safety of all the clients including the agitated client. The other provided options are not necessarily inappropriate, but none represents the best course of action.

The nurse is caring for a client who has been receiving treatment for schizophrenia with chlorpromazine for the past year. It would be essential for the nurse to monitor the client for which of the following?

Tardive dyskinesia. Tardive dyskinesia is late-appearing abnormal involuntary movements. Therefore, it is essential that the nurse monitor the client for tardive dyskinesia at this time. Weight gain, not weight loss and new-onset of diabetes (hyperglycemia), would be possible side effects of an antipsychotic. Torticollis, a dystonic reaction, would occur early in antipsychotic drug treatment.

The nurse is evaluating the plan of care for a client with schizophrenia. Which of the following observations best suggests that the plan has been effective?

The client has resumed employment and has been attending social functions at the community center.

The client's diagnosis of schizoaffective disorder is supported when the nurse documents

The client reports "hearing voices" for the last three months

The young members of a unit's psychiatric nursing staff find caring for a client newly diagnosed with disorganized schizophrenia most difficult because they find

Themselves identifying with the client since they are similarity in age Because most clients who are diagnosed with schizophrenic disorder, disorganized type, are of a young age, reactions of young staff may be to identify with the client who is close to their age or resembles someone they know. This reaction could interfere with the development of a therapeutic relationship.

A patient has been prescribed clozapine (Clozaril) for treatment of schizophrenia. The patient must be taught to monitor which blood levels weekly while taking this drug?

WBC

Which of the following is a nonneurologic side effect of antipsychotic medications?

Weight gain

Tardive dyskinesia is a late appearing sign of which type of medication?

antipsychotic agents.

A client has been on Haldol for 5 years when she is admitted to the inpatient unit for a recent exacerbation of her schizophrenic symptoms. Upon assessment, she has akathisia, dystonia, a stiff gait, and rigid posture. The nurse realizes that these are symptoms of

extrapyramidal side effects of Haldol.

A client had been withdrawn in his room for 3 days, not eating or sleeping, prior to his admission to your inpatient unit. When you interview him, the client demonstrates difficulty answering questions, appears to have no facial expressions, and cannot follow simple instructions. Together, these symptoms are commonly referred to as

negative symptoms.

The symptoms of schizophrenia represented by Bleuler's A's are

• Lack of appropriate emotional responses • Inability to think logically • Inability to relate to the world • Exhibiting of conflicting, opposing emotions

The nurse documents that the client is exhibiting negative symptoms of schizophrenia when observing the client (Select all that apply.)

• Repeatedly turning down invitations to join in unit activities • Being unable to explain the phrase, "raining like cats and dogs." Emotional isolation and a lack of abstract thinking are negative symptoms since they represents a lack of a normal function.