MH Hesi: Schizophrenia

HESI Hint: Bleuler four A's of Schizophrenia

Autism: Loss of connection w/ reality; client's thoughts are odd &internally stimulated Affect Associations: for example, loose or rapidly changing Ambivalence: Holding two different attitudes about a situation

Flow of thoughts

BLocking, concrete thinking

Assess for disturbance in affect

Blunted or flat Inappropriate Incongruent w/ situation

Assess for disturbance in perception

Hallucinations Illusions Depersonalization Delusions

What should you consider when examining for signs & symptoms of schizophrenia?

If the behavior is caused by a certain medication or an actual psychological disturbance

Assess for disturbance in behavior

Incoherant & disorganized Impulsive, uninhibited Posturing, unusual mannerisms Social withdrawal, neglect of personal hygiene Echopraxia

Word Salad

Incoherent mixture of words, phrases, and sentences

Preserveration

Repeating the same word or phrase in response to different questions

The nurse is administering risperidone to a client with schizophrenia who is scheduled to be discharged. Before discharge, which instruction should the nurse provide to the client? 1.Get adequate sunlight. 2.Continue driving as usual. 3.Avoid foods rich in potassium. 4.Get up slowly when changing positions.

Risperidone can cause orthostatic hypotension. Sunlight should be avoided by the client taking this medication. With any psychotropic medication, caution needs to be taken (such as with driving or other activities requiring alertness) until the individual can determine whether her or his level of alertness is affected. Food interaction is not a concern.

Echolalia

automatic and immediate repetition of what others say

Tangential or circumstantial speech

failing to address the original point, giving many nonessential details

Delusions

false beliefs, often of persecution, religious, somatic, or grandeur, that may accompany psychotic disorders

Hallucinations

false sensory experiences, such as seeing something in the absence of an external visual stimulus

Depersonalization

feelings of detachment from one's mental processes or body

Echopraxia

imitating another's actions

illusions

misinterpretations of real external stimuli

Assess for disturbance in interpersonal relationships

Difficulty establishing trust Difficulty w/ intimacy Fear & ambivalence toward others

Delusional Disorder

Psychotic disorder featuring a persistent belief contrary to reality (delusion) but no other symptoms of schizophrenia. Can be precipitated by a stressful event and can manifest as intense hypochondriases

Interpreting content of internal & external stimuli

Symbolism, delusions, ideas of reference

A client diagnosed with schizophrenia says to the nurse, "Will you protect me from the Grand Duchess?" and points to an older client who is sitting reading a book. Which statement is the therapeutic response by the nurse? 1."Where is she? I'll talk to her." 2."I can see no Grand Duchess. You will need to trust me on that." 3."You will be safe here. Your thinking will be clearer after your medication starts to work." 4."The Grand Duchess, huh? Well, I'm the Queen, and I will order her to stay away from you."

"You will be safe here. Your thinking will be clearer after your medication starts to work." The schizophrenic client is making a paranoid statement. It is important that the nurse provide the client with a supportive and protective intervention. The correct option is the only one that reflects a therapeutic technique, presents reality, and addresses safety. To ask, "Where is she? I'll talk to her" is not therapeutic because the nurse feeds into the client's psychosis by asking where the fantasy client is. To state that the nurse does not see the Grand Duchess and that the client needs to trust the nurse begins by presenting reality, but it does not demonstrate any real support for the client's concern with safety. To say that the nurse is the Queen and will order the Grand Duchess to stay away is sarcastic and belittling to the client.

he mental health nurse notes that a client diagnosed with schizophrenia is exhibiting flat affect. Which situation supports this documentation? 1. During the entire family visit, the client presented with an expressionless, blank look. 2. The client demonstrated minimal response to the news that his discharge had been postponed. 3. The client grimaced during the entire therapy session that focused on finding one's personal joy. 4. During grief therapy, the client was observed laughing while another client described the death of a parent.

1.During the entire family visit, the client presented with an expressionless, blank look. A flat affect is manifested as an immobile facial expression or blank look. A blunted affect is a minimal emotional response or outward affect that typically does not coincide with the client's inner emotions. A bizarre affect such as grimacing, laughing, and self-directed mumbling is marked when the client is unable to relate logically to the environment. An inappropriate affect refers to an emotional response to a situation that is incongruent with the tone of the situation.

The nurse is planning relapse prevention information for a client diagnosed with schizophrenia. The nurse understands that it is important to ensure which primary intervention? 1.Including the client's support system in the teaching 2.Facilitating weekly maintenance therapy for the client 3.Having the client restate discharge goals and strategies 4.Stressing the importance of client compliance with the medication plan

1.Including the client's support system in the teaching Of the options provided, including the client's support system in the teaching has the greatest effect on relapse prevention management because it will provide the client with valuable support. Although the remaining options are helpful, they all focus on the client's having the resources and abilities to be self-managing and self-reflective.

he nurse notes that a client with schizophrenia who is receiving an antipsychotic medication is moving her mouth, protruding her tongue, and grimacing as she watches television. The nurse determines that the client is experiencing which medication complication? 1.Parkinsonism 2.Tardive dyskinesia 3.Hypertensive crisis 4.Neuroleptic malignant syndrome

2. Tardive dyskinesia Tardive dyskinesia is a reaction that can occur from antipsychotic medication. It is characterized by uncontrollable involuntary movements of the body and extremities, particularly the tongue. Parkinsonism is characterized by tremors, mask-like facies, rigidity, and a shuffling gait. Hypertensive crisis can occur from the use of monoamine oxidase inhibitors and is characterized by hypertension, occipital headache radiating frontally, neck stiffness and soreness, nausea, and vomiting. Neuroleptic malignant syndrome is a potentially fatal syndrome that may occur at any time during therapy with neuroleptic (antipsychotic) medications. It is characterized by dyspnea or tachypnea, tachycardia or irregular pulse rate, fever, blood pressure changes, increased sweating, loss of bladder control, and skeletal muscle rigidity.

The nurse is preparing a client with schizophrenia with a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a need for additional information? 1. "My medications will help my anxious feelings." 2. "I'll go to support group and talk about what I am feeling." 3."I need to get enough sleep and eat well to help prevent feeling anxious." 4."When I have command hallucinations, I'll call a friend and ask him what I should do."

4."When I have command hallucinations, I'll call a friend and ask him what I should do." The risk for impulsive and aggressive behavior may increase if a client is receiving command hallucinations to harm self or others. If the client is experiencing a hallucination, the nurse or health care counselor, not a friend, should be contacted to discuss whether the client has intentions to hurt himself or herself or others. Talking about auditory hallucinations can interfere with subvocal muscular activity associated with a hallucination. The client statements in the remaining options will aid in wellness but are not specific interventions for hallucinations, if they occur.

A client diagnosed with schizophrenia is taking haloperidol. The nurse understands that this medication will exert its therapeutic effect through which mechanism? 1.Blocking serotonin reuptake 2.Inhibiting the breakdown of released acetylcholine 3.Blocking the uptake of norepinephrine and serotonin 4.Blocking dopamine from binding to postsynaptic receptors in the brain

4.Blocking dopamine from binding to postsynaptic receptors in the brain Haloperidol is an antipsychotic. Haloperidol acts by blocking the binding of dopamine to the postsynaptic dopamine receptors in the brain. Fluoxetine hydrochloride is a potent serotonin reuptake blocker. Donepezil hydrochloride inhibits the breakdown of released acetylcholine. Imipramine hydrochloride blocks the uptake of norepinephrine and serotonin.

The nurse is administering risperidone to a client with schizophrenia who is scheduled to be discharged. Before discharge, which instruction should the nurse provide to the client? 1.Get adequate sunlight. 2.Continue driving as usual. 3.Avoid foods rich in potassium. 4.Get up slowly when changing positions.

4.Get up slowly when changing positions. Risperidone can cause orthostatic hypotension. Sunlight should be avoided by the client taking this medication. With any psychotropic medication, caution needs to be taken (such as with driving or other activities requiring alertness) until the individual can determine whether his or her level of alertness is affected. Food interaction is not a concern.

Wh information regarding possible prognosis will the nurse provide to the parents of a 15-year-old newly diagnosed with schizophrenia? 1.Their child will very likely experience difficulty in school. 2.The prognosis for their child is good because he is so young. 3.With medication, their child is not likely to experience relapses. 4.Their child will be treated for an imbalance of the chemical dopamine.

4.Their child will be treated for an imbalance of the chemical dopamine. The dysregulation theory regarding the cause of schizophrenia shows a relationship between the brain levels of dopamine and the symptoms of schizophrenia. The prognosis is negatively affected when the onset of symptoms occurs during the adolescent years. Although medication compliance is a strong factor in minimizing the recurrence of relapses, it is not the only factor that has an effect. Moreover, although schizophrenia has an effect on reasoning and perception, the likelihood of experiencing difficulty in school is not certain.

A hospitalized client is receiving clozapine for the treatment of a schizophrenic disorder. The nurse determines that the client may be having an adverse reaction to the medication if abnormalities are noted on which laboratory study? 1.Platelet count 2.Cholesterol level 3.Blood urea nitrogen 4.White blood cell count

4.White blood cell count Clozapine is an antipsychotic medication. Clients taking clozapine can experience hematological adverse effects, including agranulocytosis and mild leukopenia. The white blood cell count should be assessed before initiation of treatment and should be monitored closely during the use of this medication. The client also should be monitored for signs indicating agranulocytosis, which may include sore throat, malaise, and fever. The remaining options are unrelated to this medication.

What must Schizoaffective disorder include?

A presence of a major mood episode

Nursing Interventions for Delusional Clients

A. Encourage recognition of distorted reality B. Divert focus from delusional thought to reality C. Do not agree with or support delusion D. Avoid arguing about the delusion E. Avoid touching client D. Administer antipsychotic drugs & monitor for side effects. Provide anticholinergic drugs as needed.

Nursing Interventions for Hallucinating Clients

A. Protect client from Injury B. Avoid denying or arguing about hallucination C. Discuss observations with your client ("You appear to be listening to something") D. Make frequent but brief remarks to interrupt the hallucination D. Give antipsychotics as ordered/needed, monitor for side effects, give anticholinergics as needed

Nursing Assessment for Delusional Disorder

Determine degree of suspicious and mistrust; degree of anxiety; determine if delusions are present, reference or control, persecution, grandeur, somatic; determine degree of insecurity

Looseness of association

Lack of clear connection from one thought to the next

Construction of verbal communication

Looseness of assocation Tangential or circumstantial speech Echolalia Neologism Preservation Word Salad

Symbolism

Meaning given to words by client to screen thoughts and feelings that would be difficult to handle if stated directly

HESI Hint: What should you observe for in clients with command hallucinations?

Observe for increased motor activity &/or erratic response to staff and other clients. They may be experiencing an increase in command hallucinations; this might potentiate aggressive behavior.

The nurse caring for a client with a diagnosis of acute schizophrenia should use which approach when planning care? 1.Allow the client to set the goals for the plan of care. 2.Let the client act out initially, and use the quiet room and restraints as needed. 3.Provide assistance with grooming and nutrition until the client's thinking has cleared. 4.Repeatedly point out inconsistencies in the client's communication during initial treatment.

Provide assistance with grooming and nutrition until the client's thinking has cleared. In the acute phase, the nurse must assume responsibility for planning for the client's basic human needs, such as nutrition, hygiene, sleep, and activities of daily living. As the nurse plans care for the schizophrenic client, it is important to understand the client's developmental stage and ability to accept the disease. The client lacks insight and may not be aware of the illness because of the severe decompensation in thinking. Including the client in decision making at this point is incorrect because these actions do not provide a structured routine. Repeatedly pointing out inconsistencies is a nontherapeutic communication technique.

The nurse is monitoring a client diagnosed with schizophrenia who demonstrates a dysfunctional affect. Which situation is congruent with inappropriate affect? 1.When told that a beloved pet has died, the client responds, "OK." 2.The client giggled while describing being physically abused as a child. 3.The client's facial expressions are unchanged during the entire admission process. 4.When staff members attempt to engage the client in conversation, the client only mumbles.

The client giggled while describing being physically abused as a child. An inappropriate affect refers to an emotional response to a situation that is incongruent with the tone of the situation. A flat affect is manifested as an immobile facial expression or blank look. A bizarre affect such as grimacing, laughing, and self-directed mumbling is marked when the client is unable to relate logically to the environment. A blunted affect is a minimal emotional response or outward affect that typically does not coincide with the client's inner emotions.

concrete thinking

Thinking grounded in immediate experience rather than abstraction. There is an overemphasis on specific detail as opposed to general and abstract concepts. Example: What is similar between apples & oranges? 'They are both round' instead of that they are both fruits

Jealousy Delusions

Usually between romantic partners; a patient is firmly convinced that her spouse is cheating on her despite contrary evidence or based on minimal data

reference delusion

belief that objects, events, or other people have particular significance to them

persecution delusion

belief that others are persecuting, spying on, or trying to harm them

somatic delusions

believes that his body is changing in an unusual way, such as growing a third arm

grandeur delusion

believing that one is a very powerful or important person

neologism

new word or expression

The nurse recognizes which assessment and diagnostic data as being associated with a newly diagnosed schizophrenic client? Select all that apply. 1.A birthday of March 30 2.A loss of interest in hobbies 3.A suicide attempt 6 months ago 4.Adopted by family at age 14 months 5.Brain scan shows increased blood flow to the frontal lobes 6.MRI shows temporal lobe atrophy

1, 2, 3, 6 A late winter, early spring birthday (viral theory); apathy and anhedonia (the inability to experience pleasure from activities usually found enjoyable); suicidal ideations; and atrophy of brain tissue are all common to individuals exhibiting symptomatology of schizophrenia. Blood flow within the brain is generally decreased; no data support that adoption itself increases the risk for schizophrenia.

Which client behavior is indicative of negative symptoms associated with schizophrenia? Select all that apply. 1. Verbal communication is almost nonexistent. 2. Gross motor skills are impacted by involuntary body movements. 3. The client needs frequent redirection because of short attention span. 4. Interpersonal relationships are negatively impacted because of delusional thoughts. 5.Conversations are difficult to follow because of demonstration of loose associations of thought.

1, 3 Negative symptoms refer to a diminishment or absence of characteristics of normal function. They may appear with or without positive symptoms. Restricted speech and attention deficits are examples of negative symptoms that generally respond to atypical antipsychotic medications. Positive symptoms reflect an excess or distortion of normal functions. Delusional thoughts (delusions), loose associations of thought, and bizarre behaviors such as inappropriate body movements are positive symptoms of schizophrenia.

Which situation will present the most prominent problem when attempting to manage the outpatient care of a client diagnosed with schizophrenia? 1.The client's noncompliance with medication therapy 2.The community's opposition to outpatient mental health clinics 3.The associated increased risk that the client may become homeless 4.The family's negative reaction to transferring the client to community-based care

1. .The client's noncompliance with medication therapy Clients often forget to take their medications as scheduled, and this is the most prominent problem since medication therapy is vital to the function of clients with such a diagnosis. While the situations described in the remaining options may occur, these problems are not as impacting on the client's prognosis and can be addressed and often controlled.

Key Symptoms of Schizophrenia

1. Positive symptoms: Psychotic symptoms are the most obvious (e.g., delusions, hallucinations, and perceptions that are not based on reality). 2. Negative symptoms: Include poverty of thought, loss of motivation, inability to experience pleasure or joy, feelings of emptiness, and blunted affect. 3. Cognitive symptoms: Include the inability to understand and process information, trouble focusing attention, and problems with working memory. The cognitive disturbances also account for the inability to use language appropriately (which is manifested by speech; e.g., looseness of association). These are the symptoms that most profoundly affect the individual's ability to engage in normal social/occupational experiences. 4. Mood symptoms: Depression, anxiety, dysphoria, suicide, and demoralization.∗

A client diagnosed with schizophrenia has been prescribed clozapine. The nurse should monitor the client for which side/adverse effects of this medication? Select all that apply. 1.Diarrhea 2.Sedation 3.Dry mouth 4.Weight loss 5.Orthostatic hypotension 6.Presence of a fixed stare

2, 3, 5, 6 Clozapine is an antipsychotic medication used to treat schizophrenia. Hallucinations, delusions, and altered thought processes are characteristic of this disorder and should decrease with effective treatment. Fixed stare, dry mouth, orthostatic hypotension, and sedation are side/adverse effects of therapy. The other options are unrelated to this medication.

A client is being seen at his primary health care provider (PHCP) office. The client has a history of schizophrenia and has been taking a new psychotropic medication for 3 weeks. Which finding(s) indicate a need for follow-up? Select all that apply. 1.The client has reported sleeping less. 2.The client's cholesterol level is elevated. 3.The client reports a decrease in appetite. 4.The client gained 8 pounds since the last visit. 5.The client's blood pressure is increased from baseline.

2, 4, 5 Clients with schizoaffective disorders are at higher incidence for metabolic syndrome and diabetes mellitus due to the side effects experienced while taking psychotropic medications, such as increase in appetite, weight gain, increased cholesterol levels, and increased blood pressure. Psychotropic medications cause sedation; therefore option 1 is incorrect.

During the admission assessment process, the nurse observes that a client diagnosed with paranoid schizophrenia has multiple dental caries and mouth ulcers. The client denies oral pain or difficulty eating and does not present any concern over the nurse's finding. The nurse recognizes the client's response as most likely the result of which client factor? 1.Apathy 2.Impaired pain perception 3.Distrust of authority figures 4.Poor verbal communication skills

2.Impaired pain perception Commonly, schizophrenia's effect on the pain center in the brain results in poor pain recognition. The client is likely not experiencing oral pain to the degree that may be felt by the individual who does not have schizophrenia. Although the remaining options may be general factors affecting this client's perceptions and personal interactions, they are not related to the pain perception threshold.

Which behavior in a client with schizophrenia demonstrates the client's cognitive inability to appropriately process data from external stimuli? 1.The client remains in the same physical position for hours. 2.The client is convinced that the curtains are actually ghosts. 3.The client looks for a cat when someone says, "It's raining cats and dogs." 4.The client repeatedly asks, "Can you see my dead sister over by the door?"

2.The client is convinced that the curtains are actually ghosts. A delusion is a personal belief that is the product of dysfunctional processing of information derived from external reality. This cognitive processing dysfunction is the basis of schizophrenia. Catatonia is a stuporous state that renders the client incapable of physical movement. Magical thinking is a result of concrete thinking that causes the client to interpret a statement literally. Hallucinations are the result of distortions in perceptions of the senses, but they are not reliant on internal or external stimuli.

The nurse is caring for a client just admitted to the mental health unit and diagnosed with catatonic stupor. The client is lying on the bed in a fetal position. Which is the most appropriate nursing intervention? 1.Ask direct questions to encourage talking. 2.Leave the client alone so as to minimize external stimuli. 3.Sit beside the client in silence with simple open-ended questions. 4.Take the client into the dayroom with other clients to provide stimulation.

3. Sit beside the client in silence with simple open-ended questions. Clients who are withdrawn may be immobile and mute and may require consistent, repeated approaches. Communication with withdrawn clients requires much patience from the nurse. Interventions include the establishment of interpersonal contact. The nurse facilitates communication with the client by sitting in silence, asking simple open-ended questions rather than direct questions, and pausing to provide opportunities for the client to respond. Although overstimulation is not appropriate, there is no therapeutic value in ignoring the client. The client's safety is not the responsibility of other clients.

he history assessment of a client diagnosed with schizophrenia confirms a routine that includes smoking 2 packs of cigarettes and drinking 10 cups of coffee daily. Considering the assessment data, the nurse recognizes which as placing the client at most risk for injury? 1.Developing lung cancer and/or other respiratory disorders 2.Withdrawal symptoms triggering a stress-induced relapse 3.Diminishing the effectiveness of psychotropic medication 4.Developing gastrointestinal disorders, including bleeding ulcers

3.Diminishing the effectiveness of psychotropic medication Both caffeine and nicotine can inhibit the action of psychotropic medications, which are commonly prescribed for schizophrenia. Although each of the remaining options presents a risk for injury, ineffective medication therapy presents the greatest risk for injury that currently affects this client.

A client diagnosed with schizophrenia has a new prescription for risperidone. Which baseline laboratory result should the nurse review before administering the first dose of this medication? 1.Platelet count 2.Blood clotting tests 3.Liver function studies 4.Complete blood count

3.Liver function studies Risperidone is an atypical antipsychotic. A baseline assessment of renal and liver function should be done before the initiation of therapy with risperidone. The medication is used with caution in clients with renal or hepatic impairment, in those with underlying cardiovascular disorders, and in geriatric or debilitated clients. These clients are started on the medication at a reduced dosage level. None of the other diagnostics are relevant to this medication.

The nurse is caring for a client diagnosed with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which question asked by the nurse has the best therapeutic value? 1."Why do you think this is a wise decision?" 2."I don't understand. Only you can help you?" 3."You've decided not to take your medication. Is that right?" 4."Do you recall what it was like before you started your medication?"

4."Do you recall what it was like before you started your medication?" Noncompliance with antipsychotic medication is 1 of the chief reasons that clients with schizophrenia have relapses. The most therapeutic response is to initiate a conversation with the client directed toward discussing the disadvantages of being noncompliant. While it is therapeutic to use communication techniques like restating and clarification, it is not useful to this client since the intent of the behavior is already understood. Asking a "why" question is usually viewed as argumentative by the client and so is not therapeutic.

The nurse reviewing a client's diagnostic results recognizes that which is a possible positive indication for a diagnosis of schizophrenia? 1.Abnormally high blood flow to the frontal lobes 2.Atrophy of both the limbic structures and cerebellum 3.Abnormally small fissures on the surface of the brain 4.Atrophy of the lateral and/or third ventricles of the brain

4.Atrophy of the lateral and/or third ventricles of the brain Imaging studies of the brains of individuals with confirmed diagnoses of schizophrenia have shown the consistent atrophy of the lateral and/or third ventricles. The remaining options are not consistent with the brain structure of individuals with schizophrenia.

Schizophrenia

A psychiatric d/o characterized by thought disturbance, altered affect, withdrawal from reality, regressive behavior, difficulty w/ communication, and impaired interpersonal relationships, as well as the inability to perceive reality

Nursing Diagnoses for Delusional Disorder

Risk for self-directed/other-directed violence r/t... Social Isolation r/t...

ideas of reference

The false impression that outside events (conversations, actions) have special meaning for oneself.

HESI Hint: Who is the client's contact with reality?

You are, the nurse

Blocking

a failure to retrieve information that is available in memory even though you are trying to produce it

Catatonia is characterized by

periods of immobility of excessive, purposeless movement Can occur in depressive, bipolar, or psychotic disorders, as well as other medical conditions