PCC IV Unit 3 Psychosis
A 23-year-old male veteran of the war in Iraq is admitted with a diagnosis of posttraumatic stress disorder (PTSD) following his arrest for destroying his girlfriend's apartment. This is not his first angry outburst resulting in destruction of property. Which interventions by the nurse will be most helpful to this patient? (Select all that apply.) a. Allow opportunities for him to express his anger. b. Provide patient and family teaching regarding PTSD. c. Tell the patient that hurting himself will solve nothing. d. Report him to the authorities. e. Exhibit a nonjudgmental attitude. f. Reassure him that everything will be all right.
ANS: A, B, E Allowing appropriate opportunities for him to express his anger will help him learn how to control his emotions or express them in a socially acceptable manner. Providing education to the patient and family will help them learn why he behaves the way he does and how to prevent or redirect his anger. Options C, D, and F are nontherapeutic in that they undermine the nurse-patient relationship. Being nonjudgmental in interactions with patients is a basic tenet of developing a therapeutic relationship.
In discussing disease prevention with a 15-year-old boy and his mother, the nurse identifies which of the following as risk factors for psychosis? (Select all that apply.) a. Father diagnosed with paranoid schizophrenia b. Rural residence c. Recent immigration from Ecuador d. Occasional cannabis use e. January birth date f. Physical abuse by the father
ANS: A, C, E, F Genetic predisposition has been identified as a risk factor for development of schizophrenia. Immigration, winter birth, and family difficulties such as abuse have also been identified as risk factors. Urban residence, not rural, and chronic cannabis use, not occasional, have also been identified.
Clients who are psychotic because of underlying psychiatric illness are treated with antipsychotic medications. Typical antipsychotic medications can improve positive symptoms in clients with schizophrenia. Positive symptoms include which of the following? (Select all that apply.) a. Hallucinations b. Disorganized speech and behavior c. Anhedonia d. Delusions e. Agitation
ANS: A, D, E Positive symptoms of schizophrenia include the distortion or exaggeration of normal behavior, such as when the client experiences hallucinations, delusions, or agitation. Negative symptoms are those that cause a loss of normal function, such as when the client exhibits disorganized speech and behavior and anhedonia.
The nurse is planning discharge teaching for a patient taking clozapine. Which information is essential to include in the teaching plan? a. Caution about sunlight exposure b. Reminder to call the clinic if fever, sore throat, or malaise develops c. Instructions regarding dietary restrictions d. A chart to record patient weight
ANS: B Fever, sore throat, and malaise are symptoms of agranulocytosis, a serious side effect of taking clozapine. Weekly blood counts are necessary to monitor for the condition. Sunlight exposure is a risk for persons taking chlorpromazine hydrochloride (Thorazine). There are no dietary restrictions for persons taking clozapine. While weight gain may occur when taking antipsychotic medication, daily monitoring is not required.
A client previously diagnosed as psychotic expresses to the nurse that he is seeing spiders climbing up the walls in his room and he is concerned that they will get into his bed. What is the nurse's best response? a. Ignore his remarks and remain silent when providing care. b. Express doubt that there are spiders on the wall. c. Ask the client if he also sees spiders in the day room. d. Tell the client there are no spiders and he should stop worrying about it.
ANS: B The client is experiencing visual hallucinations. Appropriate care for this client would not include reinforcing his hallucinations, being dismissive of him, or ignoring him. Expressing reasonable doubt is the correct answer.
Which side effect is highest priority for the nurse to assess for when diphenhydramine is administered to a patient also taking antipsychotic medication? a. Increased pychosis b. Cognitive impairment c. Respiratory depression d. Impaired memory
ANS: C Rationale: Diphenhydramine is an anticholinergic medication that may induce drowsiness or even respiratory depression taken along with anti-psychotic medication. Respiratory depression and airway are always highest priorities of care. While increased psychosis may occur, respiratory depression is highest priority. Cognitive impairment and impaired memory are not well known effects of diphyenhydramine.
A client with schizophrenia has relapsed and has been identified as being in stage four of relapse. The nurse expects to observe which behavior that most consistent with this stage of relapse? a. Expressing feelings of anxiety b. Expressing feelings of being overwhelmed c. Bizarre behaviors and speech d. Presence of hallucinations
ANS: D Schizophrenic clients who relapse go through five stages. Correctly identifying which stage the relapsing client is in is important so that interventions can be specific to the behavior. Expressing feelings of anxiety would be part of stage two, expressing feelings of being overwhelmed would be part of stage one, and bizarre behaviors and speech would be part of stage three. Presence of hallucinations is consistent with stage four, psychotic disorganization.
The nurse observes a client being treated for depression sitting with the head down and avoiding conversation with peers. What would be the nurse's priority intervention for this client? A) Ask open-ended questions about the client's feelings. B) Ask the client close-ended questions. C) Encourage a peer to sit with the client and the nurse. D) Tell the client that lack of involvement leads to more depression.
Answer: A Explanation: An open-ended question encourages more than a one-word response. Depressed clients should be comfortable with a one-to-one interaction prior to other client involvement. A closed-ended question is unlikely to encourage continued communication. Telling the client that if he does not get involved he will become more depressed is not encouraging communication.
An older client receiving pain medication for abdominal discomfort reports no relief of pain and continues to describe multiple somatic complaints. What action should the nurse take at this time? A) Further assessment and consider treatment for depression B) Obtaining an order for different pain medication C) Contacting the family to talk to the client D) Review of the client's lab values
Answer: A Explanation: Major clues to depression in the older adult include multiple somatic complaints and reports of persistent chronic pain and some vague pain. Many older people have more physical than emotional complaints. Therefore, further assessment for depression is warranted. The lab values are not indicated in this case, and obtaining different pain medication would not treat potential psychological problems. The family may also be ineffective in determining the client's psychological need.
A client with schizophrenia is unable to complete activities of daily living. The client does not respond much to what is happening, and lacks interest in the environment. What does this information indicate to the nurse? A) The client is experiencing negative symptoms. B) The client is experiencing positive symptoms. C) The client is most likely very depressed. D) The client is most likely hearing voices.
Answer: A Explanation: Negative symptoms are those that subtract from normal behavior. These symptoms include a lack of interest, motivation, responsiveness, pleasure in daily activities, or the ability to care for self. Positive symptoms include hallucinations, delusions, and a disorganized thought or speech pattern. There isn't any evidence to support that the client is hearing voices. There isn't any evidence to support that the client is very depressed.
A nurse is caring for a client with schizophrenia. The client asks the nurse what causes the disease. What is the best response made by the nurse regarding the pathophysiology and etiology of this disease? A) "Reduced blood flow to the thalamus interferes with the brain's filter, turning the normal flow of sensory information into an overload." B) "There is an increased number of nicotinic receptors in the hippocampus, which makes it harder to form new memories and interpret sensory stimuli. C) "Genetics do not seem to factor into the cause of the disease." D) "The ventricles and sulci of the brain are decreased in size."
Answer: A Explanation: There are many abnormalities of the central nervous system in a client with schizophrenia. Reduced blood flow to the thalamus interferes with the brain's filter, turning the normal flow of sensory information into an overload. A decreased number of nicotinic receptors in the hippocampus makes it harder for the client with schizophrenia to form new memories and interpret sensory stimuli. Genetics seem to factor into the cause of the disease, as familial patterns of the disease are noted. In the client with schizophrenia, the ventricle and sulci of the brain are increased in size.
The nurse is providing discharge instructions to the family of a client with schizophrenia. What should the nurse teach regarding effective communication skills? Select all that apply. A) Talk with family or friends. B) Pick a time and topic to practice. C) Decrease external stimuli. D) Leave the client alone. E) Increase the dose of medication.
Answer: A, B, C Explanation: Increasing communication in a safe setting with family and friends helps to stimulate both self-confidence and the fostering of important relationships. Asking the family to pick a time and topic to practice at home prepares them for help they can provide the client. The more the client practices skills, the more automatic they will become. Decreasing external stimuli may help the client to cope and enhance the client's ability to communicate. Increasing the dose of medication is not indicated without contacting a physician. Leaving a client alone is not a strategy to implement effective communication skills. It may overwhelm the client's ability to cope.
A client receiving chlorpromazine (Thorazine) for the treatment of schizophrenia is demonstrating signs of tardive dyskinesia. What would the nurse expect to assess in this client? Select all that apply. A) Wormlike motions of the tongue B) Lip smacking C) Unusual facial movements D) Muscle spasms of the neck E) Shuffling gait
Answer: A, B, C Explanation: 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 adolescent client is admitted to the hospital for the treatment of schizophrenia. The client's mother is confused and wants to know what she did to cause this to occur. What response(s) should the nurse give to the mother? Select all that apply. A) "Schizophrenia is a biological brain disorder." B) "Research indicates that schizophrenia is a genetic disorder." C) "Research indicates that a very stressful environment causes schizophrenia." D) "Schizophrenia is due to too much dopamine in certain parts of the brain." E) "Schizophrenia is linked to drinking alcohol during pregnancy."
Answer: A, B, D Explanation: 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 is no evidence to support a link between schizophrenia and alcohol consumption during pregnancy. A stressful environment will exacerbate the symptoms of schizophrenia but does not cause the illness.
The nurse is providing family therapy for the family of an adolescent diagnosed with schizophrenia. What is the focus of the nurse's interventions? Select all that apply. A) Establishing boundaries B) Coping mechanisms C) Providing happiness D) Preventing future episodes E) Improving communication
Answer: A, B, E Explanation: In family therapy, the family system is treated as a unit and the focus is on family dynamics. The goal is to help families cope, improve their communication and interpersonal skills, establish boundaries, and moderate family cohesion and flexibility. The nurse may not be able to prevent future psychological episodes. Emotional support is warranted, but happiness is subjective.
A client with depression is receiving electroconvulsive therapy. Which intervention(s) should the nurse plan when caring for this client? Select all that apply. A) Maintain nothing-by-mouth status until fully awake. B) Administer intravenous fluids for 8 hours post procedure. C) Place in the lateral recumbent position. D) Provide oral fluids immediately after the procedure. E) Place in the supine position with the head flat.
Answer: A, C Explanation: Care of the client recovering from electroconvulsive therapy includes placing in the lateral recumbent position to facilitate drainage and to prevent aspiration and to maintain nothing by mouth until fully awake. The supine with head flat position can lead to aspiration. The client does not need intravenous fluids for 8 hours after the procedure. Providing oral fluids when not fully awake can lead to aspiration.
The client is receiving risperidone (Risperdal) for the treatment of schizophrenia. Which client statement indicates the medication is effective? A) "I promise not to skip breakfast anymore." B) "I am not hearing the voices anymore." C) "I will start going to group therapy." D) "I feel better and I am ready to go home."
Answer: B Explanation: Among the therapeutic effects of risperidone (Risperdal) is the remission of a range of psychotic symptoms that include delusions, paranoia, auditory hallucinations, and irrational behavior. A client stating he feels better and is ready to go home, stating he will go to group therapy, or stating he will not skip breakfast does not indicate the remission of any psychotic symptoms.
An older client with cardiac disease describes a decline in the amount of sleep and difficulty falling asleep at night. What should the nurse consider is occurring with this client? A) Normal signs of cardiac disease B) Signs of anxiety and depression C) Normal signs of aging D) Normal signs of respiratory disease
Answer: B Explanation: Drastic changes in sleep patterns may be early signs of underlying anxiety and depression and should be investigated and not written off as normal changes of aging. Pain, respiratory disease, and cardiac disease can also interfere with sleep, but sleep pattern disturbances need to be assessed further to determine if there is an underlying psychiatric problem.
A client was widowed 3 years ago and has nothing to do except visit with acquaintances at the neighborhood bar. Of which health problem is this client demonstrating manifestations? A) Bipolar disorder B) Depression C) Sadness D) Extended grief
Answer: B Explanation: Risk factors for the development of depression include a history of the loss of a close family member and substance abuse. Bipolar disorder is characterized by periods of mania with periods of depression. The client is not describing or demonstrating these periods. The client may or may not be experiencing extended grief. There is not enough information to determine if the client is demonstrating sadness.
A client being treated for depression reports the desire to get out of bed, shower, eat, and contact friends and family for socialization. What should the nurse realize this client is demonstrating? A) Risk factors for self-harm B) Improvement in depression C) Denial of the diagnosis of depression D) The need for assistance with activities of daily living
Answer: B Explanation: The client reports the desire to get out of bed and is showering, eating, and contacting friends and family members. These are all indications that the client's depression is improving. This is not an indication of risk for harm, denial of the diagnosis, or the need for assistance with activities of daily living.
A nurse working in a psychiatric unit is caring for a client with schizophrenia who manifests positive symptoms of the disease. What symptom is the client likely displaying? A) Social withdrawal B) Hallucinations C) Anhedonia D) Concrete thinking
Answer: B Explanation: The major manifestations of schizophrenia are described as either positive symptoms or negative symptoms, depending on whether they involve the presence of unusual behaviors or the absence of typical behaviors. Hallucinations is a positive symptom; all other choices are negative symptoms.
The spouse of a client being treated for depression believes the client is not responding to prescribed medication. What should the nurse respond to the spouse? Select all that apply. A) "Stop the medication immediately." B) "A trial-and-error period is the best way to determine which medication is the most effective." C) "A trial of 4 to 6 weeks is usually done to see how people respond to the medication." D) "Stay on the medication for 6 months to see if there is a response." E) "Learn to live with the depression."
Answer: B, C Explanation: A trial-and-error period may be needed to determine what medication is best for the individual. About 30% of clients do not respond to their antidepressant in a trial of 4 to 6 weeks. Do not stop medications without notification of the prescriber. Antidepressant medication is often prescribed for clients with depression symptoms. Stating that the spouse will have to learn to live with the depression is inappropriate.
A nurse working in a psychiatric hospital is performing a suicide assessment on a client diagnosed with major depressive disorder (MDD). What is true regarding the suicide assessment? Select all that apply. A) Assess all clients for suicide risk by using indirect questioning. B) Ask if the client has any thought of suicide. C) Asking about suicide will "plant the idea" in the client's mind. D) Assess the lethality of the suicide plan, if one exists. E) If the client has suicidal thoughts, assess whether or not the client would act on them.
Answer: B, D, E Explanation: When performing a suicide assessment, the nurse should always use direct, not indirect, questioning. The nurse should ask if the client has any thought of suicide and assess the lethality of the suicide plan, if one exists, and whether or not the client will act on these thoughts. Asking about suicide will not "plant the idea" in the client's mind.
The nurse is helping the family of an adolescent understand why their child has been diagnosed with schizophrenia. What should the nurse explain as a risk for the development of schizophrenia? A) Association with psychotic clients B) Smoking C) Genetic predisposition D) Allergy to shellfish
Answer: C Explanation: Studies have shown that there is a genetic predisposition to the development of schizophrenia. Smoking, allergies to foods, and association with others have not been shown to cause schizophrenia.
A client with schizophrenia is exhibiting attention deficit and difficulty remembering recent events. What is an appropriate expected outcome for this client? A) Client will interact well with others before discharge. B) Client will develop occupational skills by discharge. C) Client will exhibit an increased attention span in 1 week. D) Client will deny auditory hallucinations within 7 days.
Answer: C Explanation: This client is exhibiting the cognitive disturbances of attention deficit and difficulty remembering. The only outcome applicable to this situation is that the client will exhibit an increased attention span.
The nurse is caring for a client who is experiencing auditory hallucinations. What would be the priority nursing diagnosis for this client? A) Disturbed Thought Processes B) Individual Ineffective Coping C) Impaired Verbal Communication D) Risk for Violence, Self-Directed or Other-Directed
Answer: D Explanation: Maintaining a safe environment is the priority diagnosis. Although the client has impaired thought processes, this is not the priority diagnosis at this time. Individual Ineffective Coping and Impaired Verbal Communication are also correct diagnoses, but the key word here is "priority," and this client has a potential or risk for harm to self or others.
The physician has prescribed aripiprazole (Abilify) for the client with schizophrenia. What would be a priority outcome for the client? A) The client will report a decrease in auditory hallucinations. B) The client will report symptoms of restlessness. C) The client will consume adequate fluids and a high-fiber diet. D) The client will be compliant with taking the medication as prescribed.
Answer: D Explanation: Medication compliance is a priority for clients 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 aripiprazole (Abilify), but this is not the priority outcome.
A nurse is caring for a client who displays symptoms associated with seasonal affective disorder (SAD). What healthcare provider order would the nurse question as inappropriate for this client? A) Cognitive-behavioral therapy B) Light therapy C) Bupropion extended-release D) Selective serotonin reuptake inhibitor (SSRI)
Answer: D Explanation: The nurse would question the order for a selective serotonin reuptake inhibitor (SSRI). This medication is used in the treatment of major depressive disorder (MDD) and dysthymic disorder, not seasonal affective disorder (SAD). All the other orders are appropriate for a client with SAD.
A client being treated for depression reports feeling better and has started to make plans. What is a priority nursing concern? A) Social Isolation B) Hopelessness C) Situational Low Self-Esteem D) Risk for Self-Directed Violence
Answer: D Explanation: The one risk that occurs with successful treatment of a client with depression is that once the depression begins to resolve, the underlying thought of suicide could prevail. With treatment, the client may begin to have more energy to make a plan regarding suicide. The nurse should further assess this client's statement about making plans. The client is not demonstrating low self-esteem, hopelessness, or social isolation.
