Chapter 16: Schizophrenia

A client with schizophrenia states that the client is God's messenger and the client's mission is to become president. The nurse documents these comments as evidence of what?

Delusional thinking Explanation: Delusions involve disturbances in thought content. They are firmly held false beliefs that reasoning cannot correct and for which there is no support in reality.

A comprehensive nursing assessment for neuroleptic malignant syndrome (NMS) should include checking for which in a client taking an antipsychotic medication?

Muscular rigidity, tremors, and difficulty swallowing Explanation: NMS is characterized by muscular rigidity, tremors, difficulty swallowing, fever, hypertension, and diaphoresis.

A client has been taking neuroleptic medications for many years as a treatment for schizophrenia. The client is exhibiting tongue protrusion, facial grimacing, and excessive blinking. These manifestations are characteristic of which side effect?

Tardive dyskinesia Explanation: Unusual movements of the tongue, neck, and arms suggest tardive dyskinesia, an adverse reaction to neuroleptic medication. Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles. Neuroleptic malignant syndrome causes rigidity, fever, hypertension, and diaphoresis. Akathisia causes restlessness, anxiety, and jitteriness.

Which statement made by a client would indicate that the client has delusions of grandeur?

"I am a magician, and my magic powers are good when the moon is full." Explanation: The correct answer is the only statement that reflects that the client believes the client has powers, abilities, or characteristics that go beyond those of normal individuals (delusions of grandeur).

A client tells the nurse that the client has bugs in the client's brain and asks the nurse if the nurse can see them. Which response by the nurse is most therapeutic?

"No, I don't see any bugs. That sounds scary for you." Explanation: The person who hallucinates is preoccupied and frightened by what he or she hears or sees. The hallucination is real to the client, and the nurse cannot argue away, dismiss, or ignore it. Although the hallucination is real to the client, nurses make it clear that they do not hear the voices or see the visual images. Nurses do, however, communicate concern that the client is bothered, upset, or frightened by the hallucination.

The nurse is teaching a client with schizoaffective disorders (SAD) about the client's prescribed medication therapy. The nurse determines that additional education is needed when the client states what?

"One day, I won't have to worry about taking any medication." Explanation: After the client's condition has stabilized (i.e., the client exhibits a decrease in positive and negative symptoms), the treatment that led to remission of symptoms should be continued. Titrating antipsychotic agents to the lowest dose that provides suitable protection may enable optimal psychosocial functioning while slowing the recurrence of new episodes. Clients diagnosed with SAD are unlikely to be medication free. Clients also need education about preventing orthostatic hypotension, such as changing positions slowly, as well as drinking adequate amounts of fluid each day. Clients also need to notify their health care provider if they notice any abnormal muscle movement or the inability to control motor movement.

A client with a persecutory delusion has been explaining to the nurse the specifics of the conspiracy against the client. The client pauses and says, "I get the feeling that you don't actually believe that what I'm telling you is true." How should the nurse respond?

"What you're telling me is difficult for me to believe. This may be real for you, but not me." Explanation: While an empathic approach is crucial when interacting with persons who have a delusional disorder, this does not involve expressing or implying that the nurse believes the person's delusions are real. If confronted by the client on this fact, this is best stated clearly.

Which client exhibits the characteristics that are typical of the prodromal phase of schizophrenia?

A 20-year-old is experiencing a gradual decrease in the ability to concentrate, be productive, and sleep restfully. Explanation: Gradual, subtle behavioral changes appear during the prodromal phase of schizophrenia, such as tension, the inability to concentrate, insomnia, withdrawal, or cognitive deficits. No symptoms are present in the premorbid phase, and relapses occur in the progressive and chronic phases. Diagnosis of the disease marks the beginning of the onset phase.

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

Agranulocytosis Explanation: 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 nurse monitoring client medication needs to recognize side effects quickly and intervene promptly for which reason?

Alleviate the side effects and help client maintain adherence Explanation: Recognizing a medication's side effects quickly and intervening promptly to alleviate them will help maintain adherence.

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

Ask the client if the client is trying to say that something is wrong with the client's arm. Explanation: 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.

Which constitutes a negative symptom associated with schizophrenia?

Asociality Explanation: Asociality is characterized by social withdrawal, few or no relationships, and lack of closeness. These are recognized as negative symptoms of schizophrenia in accordance with the DSM-V. The other options listed are examples of positive symptoms of schizophrenia.

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

Bathing self-care deficit related to symptoms of schizophrenia Explanation: 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. The family's desire to care for the client does not support a nursing diagnosis of dysfunctional family processes. There is no evidence of ineffective role performance or social isolation at this time.

Which would a nurse expect to administer to a client with schizophrenia who is experiencing a dystonic reaction?

Benztropine Explanation: A client experiencing a dystonic reaction should receive immediate treatment with benztropine. Risperidone and aripiprazole are antipsychotics that may cause dystonic reactions. Trihexyphenidyl is used to treat parkinsonism due to antipsychotic drugs.

Which medication is used to control the extrapyramidal effects associated with antipsychotic medications?

Benztropine Explanation: Benzotropine is an anticholinergic drug used to relieve drug-induced extrapyramidal adverse effects, such as muscle weakness, involuntary muscle movement, pseudoparkinsonism, and tardive dyskinesia.

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

Biologic Explanation: 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.

A nurse is preparing to document information obtained from a client diagnosed with a delusional disorder who is experiencing somatic delusions. Which would the nurse most likely document?

Body complaints Explanation: Somatic delusions involve bodily functions or sensations, with clients believing that they have physical ailments. Clients with delusional disorder show few, if any, psychological deficits. These clients characteristically have average or marginally low intelligence. Mental status generally is not affected. Thinking, orientation, affect, attention, memory, perception, and personality are generally intact.

A client with schizoaffective disorder is engaging in an extremely long conversation about a current affairs in the world. The client goes on to provide the nurse with minute details. The nurse interprets this as suggesting what?

Circumstantiality Explanation: The client is demonstrating circumstantiality, which refers to extremely detailed and lengthy discourse about a topic.This can be commonly found in a client with euphoric or elevated mood due to the affective component of schizoaffective disorder. 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. A verbigeration is the stereotyped repetition of words or phrases that may or may not have meaning to the listener.

Which speech pattern is exhibited by the client stating, "I will take a pill if I go up the hill but not if my name is Jill, I don't want to kill?"

Clang association Explanation: 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. A verbigeration is the stereotyped repetition of words or phrases that may or may not have meaning to the listener. A word salad is a combination of jumbled words and phrases that are disconnected or incoherent and make no sense to the listener.

The nurse is caring for a client who was just admitted with a diagnosis of schizoaffective disorder with depression. Which agent would the nurse anticipate as being prescribed for this client?

Clozapine Explanation: Atypical antipsychotic agents are generally prescribed because of their efficacy and safe side effect profile. These agents have a mood-stabilizing, as well as antipsychotic, effect. Clozapine has been reported to be effective for this disorder. Lithium might be an alternative for clients experiencing mood states associated with the bipolar type. Haloperidol and chlorpromazine are typical antipsychotic agents.

The nurse is developing a care plan for a client with somatic delusions. Which would be an appropriate nursing diagnosis for this client?

Disturbed thought process Explanation: The most appropriate nursing diagnosis for this client is disturbed thought process related to misperception of environmental stimuli. Disturbed sleep pattern, risk for self-directed violence, and chronic low self-esteem would not be the most appropriate nursing diagnosis for this client.

A client diagnosed with schizoaffective disorder and severe depression is being treated with antipsychotic medications. The client tells the nurse about difficulty with self-care activities. With which intervention should the nurse respond?

Establish a routine and set goals. Explanation: The most useful approach for the nurse to try is to help the client establish a routine and set goals for accomplishing the activities of daily living.

How often must clients receiving clozapine get white blood cell counts drawn?

Every week for the first 6 months Explanation: Clients taking clozapine must have weekly white blood cell counts for the first 6 months of clozapine therapy and every 2 weeks thereafter.

A client with delusional disorder tells the nurse that the client has discovered how to jump to the moon. The nurse would document this belief as what?

Grandiose delusion Explanation: Clients presenting with grandiose delusions are convinced they have a great, unrecognized talent or have made an important discovery. A less common presentation is the delusion of a special relationship with a prominent person (i.e., an adviser to the president) or of actually being a prominent person (i.e., the president). The central theme of the jealous delusion is the unfaithfulness or infidelity of a spouse or lover. The central theme of somatic delusions involves bodily functions or sensations. These clients believe they have physical ailments. Erotomanic delusions are characterized by the delusional belief that the client is loved intensely by the "loved object," who is usually married, of a higher socioeconomic status, or otherwise unattainable. The client believes that the loved object's position in life would be in jeopardy if his or her true feelings were known.

During an admission assessment, a client with schizoaffective disorder states that the client hears the voice of God in the client's head and the voice is telling the client that the client is worthless. What would the nurse document this symptom as?

Hallucination Explanation: Hallucinations are sensory perceptions with a compelling sense of reality but with no actual objective basis. During auditory hallucinations (the most common form), clients may hear the voice of God or close relatives, two or more voices with a running commentary about the client's behavior, or voices that command certain acts. Delusions are false, fixed beliefs. Avolition involves the withdrawal and inability to initiate and persist in goal-directed activity. Alogia refers to the reduced fluency and productivity of thought and speech.

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

Hyponatremia Explanation: Hyponatremia is a life-threatening complication of unknown cause. When a client ingests an unusually large volume of water, the kidneys' capacity to excrete water is overwhelmed, and serum sodium concentrations rapidly fall below the normal range.

A client with delusions presents with strong defensiveness, even when watching the news or listening to the radio. The nurse would document this finding in the health history as what?

Ideas of reference Explanation: Ideas of reference occur when a client has self-centered thoughts and falsely believes ideas are centered on something the client is doing, thinking, or feeling. Looseness of association is the inability to think logically. Ambivalence refers to contradictory or opposing emotions, attitudes, ideas, or desires for the same person or things or toward the environment. Echolalia is a pathological parrot-like response of a word or phrase.

Catatonia as seen in clients with schizophrenia is unique in the existence of which feature?

Immobility like being in a trance Explanation: Catatonia, as seen in clients with schizophrenia, is a psychologically induced immobility occasionally marked by periods of agitation or excitement; the client seems motionless as if in a trance.

Positive symptoms seen in schizophrenia are believed to be a result of which type of neurological dysfunction?

Increased amount of dopamine Explanation: Positive (or productive) symptoms reflect an increased amount of dopamine affecting the cortical areas of the brain. Negative symptoms reflect an inadequate amount of dopamine, cerebral atrophy, and organic functional changes in the brain.

A student nurse has been assigned to provide care for an inpatient psychiatric-mental health client who has a diagnosis of schizophrenia. The student nurse is apprehensive about interacting with the client. The client's detailed explanations of the client's delusions accompanied by unpredictable movements have prompted fear in the student. How should this nursing student interpret such feelings?

It is natural to feel fear when a client exhibits unpredictable behavior, and this can cause the student to be reasonably cautious. Explanation: A student may experience fear if the client exhibits unpredictable behavior. Fear is a normal response that results in the exercise of caution. Experiencing fear is not evidence of stereotyping, and divulging fear to the client is unlikely to benefit either the student or the client. The risk of violence is a reality, though the risk differs with each client.

The nurse must be aware that individuals from diverse ethnic groups might describe troubling experiences in terms of physical problems or specific culture-bound syndromes. The syndrome of ghost sickness is exhibited by which culture?

Native American Explanation: The culture-bound syndrome of ghost sickness is seen in the Native American tribal culture. This culture exhibits a preoccupation with death and the deceased. Bad dreams, weakness, feelings of danger, anxiety, and hallucinations may occur. The other options are not related to the culture-bound syndrome of ghost sickness.

A client with schizophrenia is receiving antipsychotic therapy. The nurse understands that which is a medical emergency should it develop in the client?

Neuroleptic malignant syndrome Explanation: Although tardive dyskinesia, parkinsonism, and akathisia can occur with antipsychotic therapy, neuroleptic malignant syndrome is a life-threatening condition and medical emergency that requires immediate treatment.

A client has been prescribed quetiapine for delusional disorder. In teaching the client about this medication, the nurse must be certain to include which information?

One of the common side effects is dry mouth. Explanation: Dry mouth is a common, sometimes bothersome, side effect. Quetiapine does not cause breast milk production. Dizziness may occur due to orthostatic hypotension but will decrease as the body becomes accustomed to the medication. It is not an emergency. Quetiapine can cause changes in blood sugar but will not induce sugar cravings.

A 44-year-old client has been experiencing intense job stress. In recent weeks, the client has confided in the client's spouse that the client believes the client's firm monitors every aspect of the client's personal performance and that the firm is engaged in deception and cover-up of its "true purpose." A nurse would recognize that the primary theme of the client's delusional disorder is what?

Persecutory Explanation: Clients who exhibit persecutory delusions believe that they are being conspired against, spied on, poisoned or drugged, cheated, harassed, maliciously maligned, or obstructed in some way. This delusion is not characteristic of somatic, conjugal, or grandiose subtype.

A mental health client insists that the client's spouse is trying to poison the client. In this instance, the client is exhibiting which type of delusion?

Persecutory Explanation: Clients who exhibit persecutory delusions believe that they are being conspired against, spied on, poisoned, or drugged. Somatic delusions demonstrate a preoccupation with the body. A client exhibiting erotomanic delusions believes that a person of elevated social status loves him or her. Grandiose delusions are present when the client believes that he or she possesses unrecognized talent or insight or has made an important discovery.

While being assessed, a client with schizophrenia states, "Everywhere I turn, the government is watching me because I know too much. They are afraid that I might go public with the information about all those conspiracies." The nurse interprets this statement as indicating which type of delusion?

Persecutory Explanation: Persecutory delusions involve the belief that one is being watched, ridiculed, harmed, or plotted against. Grandiose delusions involve the belief that one has exceptional powers, wealth, skill, influence, or destiny. Nihilistic delusions involve the belief that one is dead or a calamity is impending. Somatic delusions involve beliefs about abnormalities in bodily functions or structures.

During a client interview, a client diagnosed with delusional disorder states, "I know my spouse is being unfaithful to me with a colleague from work."The nurse interprets the client's statements as suggesting which type of delusion?

Persucatory/paranoid Explanation: The client's statements reflect persucatory/paranoid delusions that focus on the unfaithfulness or infidelity of a spouse or lover. Such delusions involve the belief that others are untrustworthy in some way. With referential delusions, the ideas of reference involve the client's belief that television broadcasts, music, or newspaper articles have special meaning for him or her. In the sexual delusion subtype, ideas involve the belief that the client's sexual behavior is known to others. With grandiose delusions, individuals believe that they have a great, unrecognized talent or have made an important discovery.

A 24-year-old with schizophrenia and paranoid delusions 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. Explanation: A newly admitted client with paranoid schizophrenia needs a sense of trust before the nurse attempts to touch the client. Using emphatic tones and veiled threats will only increase the client's anxiety and lead to increased potential for hostility and anger.

A client with schizophrenia is exhibiting positive and negative symptoms. The nurse anticipates that the client would be prescribed what?

Second generation antipsychotic Explanation: The second-generation antipsychotics are effective in treating negative and positive symptoms. These newer drugs also affect several other neurotransmitter systems, including serotonin. This is believed to contribute to their antipsychotic effectiveness. None of the other agents would be appropriate.

A client with a long history of schizophrenia has managed well on fluphenazine. The client reports smacking of the lips and sticking out the tongue. Based on this report, what does the nurse suspect is occurring with the client?

Signs of tardive dyskinesia (TD) associated with neuroleptic medication Explanation: TD is a type of extrapyramidal side effect characterized by abnormal, involuntary, irregular, choreoathetoid (writhing) movements, which may include lip smacking, neck twisting, facial grimacing, and tongue and chewing movements. TD can occur after several months to years of therapy with traditional antipsychotics.

A client is receiving antipsychotic therapy. When describing dystonic reactions to the client,the nurse would instruct the client to watch for:

Spasms of the eye muscles Explanation: Dystonic reactions are also believed to result from the imbalance of dopamine and acetylcholine, with the latter dominant. This side effect, which develops rapidly and dramatically, can be very frightening for clients as their muscles tense and their body contorts. The experience often includes spasms of the eye muscles called oculogyric crisis, in which the muscles that control eye movements tense and pull the eyeball so that the client is looking toward the ceiling. Restless is otherwise called akathesia. This is considered one form of extrapyramidal symptoms but is not an acute dystonic reaction. Lip smacking and facial grimacing are characteristic of tardive dyskinesia.

When developing the plan of care for a client with schizophrenia who is in the acute phase of illness, the nurse understands that the client is at high risk for what?

Suicide Explanation: During the acute illness, individuals with schizophrenia are at high risk for suicide. Clients are hospitalized usually to protect themselves or others. Clients with schizophrenia who have an abnormality in the hippocampus may experience disordered water balance, whereupon individuals drink compulsively as a result of neuroendocrine dysfunction, placing them at risk for water intoxication. However, this is not the priority. Mania and depression are unrelated to schizophrenia during the acute illness.

Research related to the development of schizophrenia has shown what?

The disorder is thought to arise from the interaction of a biological predisposition and environmental stressors. Explanation: The likelihood of first-degree relatives (including siblings and children) developing schizophrenia has long been recognized as 10 times more likely than individuals in the general population. While this likelihood clearly suggests a strong genetic factor, the concordance for schizophrenia among monozygotic (identical) twins is 50%, suggesting that there are also environmental factors. Schizophrenia is believed to be caused by the interaction of a biologic predisposition or vulnerability and environmental stressors.

A client with schizophrenia is prescribed an antipsychotic medication. Which immediate side effects would the nurse include in the education plan for this medication?

The potential for sedation Explanation: Sedation with antipsychotic medication will likely happen immediately after initiating the medication. The nurse should be sure to inform the client they he or she will experience this side effect readily. The other options are examples of side effects that are possible with longer term treatment using antipsychotic medications. Weight gain is commonly associated with many antipsychotic medications. The potential for weight loss with antipsychotic medication is not typically discussed with clients.

A client is diagnosed with a delusional disorder. While providing care to the client, the nurse assesses the client's delusions. Which would be least appropriate for the nurse to do?

Try to change the client's delusional belief Explanation: By definition, delusions are fixed, false beliefs that cannot be changed by reasonable arguments. The nurse should assess the client's delusion to evaluate its significance to the client, to the client's safety, and to the safety of others. The nurse should not dwell on the delusion or try to change it.

Which statements characterizes the major difference between the typical and atypical antipsychotic medications?

Typical antipsychotics most often relieve positive symptoms but do not have a significant impact on negative symptoms. Explanation: Traditional antipsychotics treat the positive symptoms of schizophrenia (i.e., hallucinations and delusions). Atypical antipsychotics relieve both the positive and negative symptoms (e.g., apathy, avolition, social withdrawal) of schizophrenia and are less likely to cause distressing extrapyramidal side effects typically seen with traditional antipsychotics.

A client diagnosed with schizophrenia states, "I want to go home, go home, go home." This is an example of which speech pattern?

Verbigeration Explanation: A verbigeration is the stereotyped repetition of words or phrases that may or may not have meaning 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. A word salad is a combination of jumbled words and phrases that are disconnected or incoherent and make no sense to the listener.

A client is admitted to the psychiatric hospital with a diagnosis of schizophrenia. During the physical examination, the client's arm remains outstretched after the nurse obtains the pulse and blood pressure, and the nurse must reposition the arm. The nurse interprets this as what?

Waxy flexibility Explanation: Waxy flexibility, the ability to assume and maintain awkward or uncomfortable positions for long periods, is characteristic of catatonic schizophrenia. Clients commonly remain in these awkward positions until someone repositions them. Exchopraxia refers to the involuntary imitation of another person's movements and gestures. Hypervigilance refers to the sustained attention to external stimuli, as if expecting something important or frightening to occur. Retardation refers to slowed movements.

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

continuity of care Explanation: 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. Although inpatient hospitalizations that are brief and focus on client stabilization, crisis management as key to emergency care, and decreased social isolation through social engagement are all important, they are not considered major goals for recovery.

A client with schizophrenia is prescribed clozapine. The nurse would monitor the client closely for specific signs of:

infection. Explanation: Agranulocytosis can develop with the use of all antipsychotic drugs, but it is most likely to develop with clozapine use. Therefore, the nurse needs to be alert for signs of infection, particularly bacterial infection. Hypotension may occur with any antipsychotic drug. Nausea is a common side effect of many drugs. Weight gain, not loss, can occur with olanzapine and clozapine.

A client diagnosed with delusional disorder who uses excessive health care resources most likely has which type of delusions?

somatic Explanation: Persons who have somatic delusions believe they have a physical ailment. Clients with somatic delusions use excessive health care resources. The central theme of the jealous subtype is the unfaithfulness or infidelity of a spouse or lover. Erotomanic delusions are characterized by the delusional belief that the client is loved intensely by the "loved object," who is usually married, of a higher socioeconomic status, or otherwise unattainable. Clients presenting with grandiose delusions are convinced they have a great, unrecognized talent or have made an important discovery; a less common presentation is the delusion of a special relationship with a prominent person or actually being a prominent person.

A 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:

tardive dyskinesia. Explanation: 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) are possible side effects of an antipsychotic. Torticollis, a dystonic reaction, would occur early in antipsychotic drug treatment.