Schizophrenia, Personality Disorders, Anger, Aggression, and Violence

Schizotypal Personality Disorder

"latent schizophrenics"—behaviors odd and eccentric but does not decompensate to the level of schizophrenia Odd appearance: unkempt and disheveled Aloof and isolated: discomfort in relationships—prefer solitary activities; often experience occupational difficulties; social situations cause anxiety Magical thinking, ideas of reference, illusions and depersonalization: i.e. having special powers), ideas of reference (client's belief that events have special meaning to him) that influence behavior Bizarre speech pattern: coherent but often vague, circumstantial, metiphorical Can develop psychotic symptoms (delusional thoughts, hallucinations, or bizarre behavior)—cognitive and behavior distortions Can develop psychotic symptoms (delusional thoughts, hallucinations, or bizarre behavior) Nursing Interventions: develop self-care skills; encourage daily routine improve community functioning; social skills training

schizophrenia behaviors: behaviors leading to social/occup. dysfunction

-Inability to communicate coherently -Loss of drive & interest -Deterioration of social skills -Poor personal hygiene -Paranoia Again, at the center of the core symptoms clusters in schizophrenia is Social/Occupational Dysfunction—social problems are often the major source of concern for family and health care providers because these tangible effects of illness are often more prominent then the symptoms r/t cognition and perception. Specific problems in the development of relationships include: Social inappropriateness (suddenly being loud, toileting in public, standing in the middle of the street trying to direct traffic)---who determines what is socially acceptable??? What about culture??? Inappropriate sexual behavior (inappropriate sexual advances)—not uncommon for people with schizophrenia to be unable to recognize their genitalia as their own—this often is the reason for sudden undressing and what appears to be public masturbation with it is merely a patients futile attempt at reality testing. Stigma related withdrawal by friends, families, peers—pulling away r/t shame associated with schizophrenia—patient as well as family (family may not want to talk about it) Consider age of onset too—(17-25)—patient with schizophrenia can be very isolated by choice or by others actions.—classmate..no clue what was wrong with him...in high school he just started acting really weird. Poor eye contact is often a characteristic. For those of you who have gone to the Rock, Walter has poor eye contact.

Potential Early Symptoms: Prepsychotic

-Withdrawn from others -Depressed -Anxious -Phobias -Obsessions and compulsions -Difficulty concentrating -Preoccupation with religion -Preoccupation with self Men more often with age of onset 18 to 25 years Women more often with age of onset 25 to 35 years --age of onset appears to be an important factor in how well the client does—earlier onset fare worse

schizophrenia assessment guidelines

1. Any medical problems 2. Abuse of or dependence on alcohol or drugs 3. Risk to self or others 4. Command hallucinations 5. Belief system 6. Suicide risk 7. Ability to ensure self-safety 8. Medications 9. Presence and severity of positive and negative symptoms 10. Patient's insight into illness 11. Family's knowledge of patient's illness and symptoms Rule out medical issues first. It is important to assess whether the patient has had a medical workup, including evaluation for the presence of psychosis, and whether the patient is dependent on alcohol or other drugs. Is the individual experiencing hallucinations or delusions? Are they aware when they experience delusions and hallucinations? What is their support system

Family members ask the nurse about their relative's chance of a positive outcome after being diagnosed with schizophrenia. Which of the following information should the nurse provide the family? (Select all that apply) A.Good premorbid functioning can predict a positive outcome B.Early age of onset can predict a positive outcome C.Being male can predict a positive outcome D.An abrupt onset of symptoms can predict a positive outcome E.An associated mood disorder can predict a positive outcome

A,D,E Abrupt onset rather than gradual insidious onset of symptoms (insidious gradual/subtle but harmful effects)

Negative symptoms

Alogia: poverty of speech (restricted thought or speech). Patient answers questions briefly to monosyllabic answers. Or speech is adequate in amount but conveys little information because of vagueness or obscure phrases -reduction in spontaneity or volume of speech, can be short stunted answers Avolition/apathy: lack of motivation, unable to initiate tasks (grooming or other ADL's deterioration of appearance, social contacts etc) or don't seem to care attitude. -Avolition: Reduced motivation and spontaneous activity, inability to initiate tasks such as grooming, or social contact Anhedonia: inability to experience any pleasure in activities, profound emotional baroness. (also present with depression) inability to experience pleasure in activity the person normally would. Anergia: lack of energy, passiveness Ambivalence Sudden interruption in the thought process: usually due to internal stimuli (loose their place) Affect -Flat: blank -Blunted: reduced -Inappropriate: incongruent response -Bizarre: grimacing, giggling, etc.

Positive Symptoms

Alteration of thought Concrete thinking: failure to abstract Delusions—false fixed beliefs that cannot be corrected by reasoning. They may be simple or complex. They may not last. -Paranoid: involves the patients belief that others are planning to harm the patient or are spying, following, ridiculing, or belittling the client in some way. -Grandiose: patient claims to associate with famous people or celebrities, or the patient belief that he or she is famous or capable of great feats. -Religious: Religious—belief that one is favored by a higher being. (overlaps with grandiose) Belief that one is Jesus Christ or is the chosen one and they have special powers -Somatic: believe they have some physical defect, disorder, or disease (emits a foul odor from the skin, mouth, etc; has infestion of insect in or on skin; has internal parasites; has misshapen and ugly body parts; has dysfunctional body parts) Thought broadcasting Thought insertion or withdrawal Ideas of reference Some delusions hold a kernal of truth, for example a patient may have the delusion that the mafia is out to kill him when in actuality someone is after him for not paying his debts. Patients truly believe that their delusions are true. Alterations in perception Depersonalization Derealization Hallucinations -are another positive symptom and are problems of Perception -Hallucinations—false sensory perception for which no external stimulus exists. The patient actually experiences the sensory distortion as being real and responds accordingly. There are different types of hallucinations—auditory the most common—hearing voices or sounds. May be command hallucinations where the voices may command the person to hurt himself or others. "The voices are telling him to jump out the window" or to take a knife and kill the child", (they may start out friendly but get mean) -http://www.janssen.com/janssen/news_mindstorm.html -Tactile: feeling body sensations.- experiencing pain or discomfort with no apparent stimuli -Auditory: hearing sounds -Visual: seeing persons or things -Olfactory: smelling odors -Gustatory: experiencing tastes Alterations in speech-Associative Looseness Neologisms: made-up words that have meaning for the patient, but a different or non-existent meaning for others Echolalia: pathological repeating of another's words Clang associations: choosing words based on their sound rather than their meaning (rhyming can occur) Word salad: (schizophasia) - jumble of words that is meaningless to the listener, and sometimes also for the speaker Circumstantiality: including unnecessary and often tedious details in one's conversation Tangentiality: tangential speech - leaving the main topic to go off about less important topics Other disorders of thought or speech Magical thinking: believing one's thoughts or actions can affect others Perseveration

Anger and Aggression

Anger -An emotional response to frustration of desires, threat to one's needs (emotional or physical), or a challenge Aggression -Action or behavior that results in verbal or physical attack Anger and aggression are difficult targets for nursing intervention, particularly if their focus is the nurse, because they imply threat and elicit emotional and personal responses. Anger is an emotional response to the perception of frustration of desires, threat to one's needs, or challenge. Aggression is harsh physical or verbal action that reflects rage, hostility, and potential for physical or verbal destructiveness. Anger and aggression are the last two stages of a response that begins with feelings of vulnerability followed by uneasiness. Intervention in the early stages is desirable.

two groups of antipsychotics

Antipsychotic Medications alleviate symptoms but do not eliminate them Typical -Traditional, conventional, first generation -Oldest -Target + symptoms -Many side effects Atypical -Second generation -Developed late 1980's -Target + and - symptoms -Fewer side effects

Paranoid Personality Disorder

Anxious about being harmed Suspicious of others: constantly on guard-ready for any real or perceived threat Fear of exploitation, harm, deceit: unwillingness to forgive—often appears jealous (r/t suspicion that partner is cheating) Misread compliments as manipulation: extremely oversensitive and tend to misinterpret even minute cues in the environment—magnifying them and distorting them Hostile, aloof Psychotic in times of stress Maintain self-esteem by attributing their shortcoming to others—they project their own behaviors and beliefs onto others. Research has indicated a possible genetic link—connected to aggressive parents Nursing interventions: form an effective working relationship--straightforward explanations—to counteract the fears; teach patient to validate ideas before taking action; involve them in the treatment planning (help them feel in control)

Cluster C Personality Disorders

Anxious or fearful behavior Rigid patterns of social shyness Examples -Avoidant PD -Dependent PD -Obsessive-compulsive PD

Strategies/Interventions Cluster A

Approach client in a gentle, interested, nonintrusive manner Respect clients needs for distance and privacy Be cognizant of non-verbal cues, as a client may perceive others as threatening. Gradually encourage interactions with others, if and when appropriate

anger, aggression, and violence assessment

Assess for signs and symptoms that indicate risk of escalating anger Trauma-informed care -Focus on patients' past experiences of violence or trauma and the role aggression currently plays in their lives S/S: Expressions of anxiety and anger look quite similar: increased rate and volume of speech, increased demands, irritability, frowning, redness of face, pacing, twisting hands, or clenching and unclenching of fists. Past experience: The single best predictor of future violence is a history of violence. Patients who are delusional, hyperactive, impulsive, or predisposed to irritability are at higher risk for violence. Patients with a history of limited coping skills, including lack of assertiveness or use of intimidation, are at higher risk of using violence. Assess self for personal triggers and responses likely to escalate patient violence and assess personal sense of competence. Is there a past history of aggression, etc.

schizophrenia affect symptoms

Assessment for depression crucial -May herald impending relapse -Increases substance abuse -Increases suicide risk -Further impairs functioning Depression recognition during assessment is crucial because depression affects a majority of people with schizophrenia. It may herald a psychotic relapse, increase the likelihood of substance abuse or suicide, or may be associated with impaired functioning.

schizophrenia interventions: managing delusions

Avoid openly confronting or arguing Avoid playing along Present reality: "I have seen no evidence of that" Cast doubt "It doesn't seem that way to me." Distraction helps minimize the effects of delusional thinking Rely on empathy. Clarify the reality of patient's experience. Do not focus on delusional content. Do not use logic to refute delusion and do not argue. Clarifying misinterpretations is useful. Spend time with patient in reality-based activities. Presenting reality and casting doubt work best when medications start to take effect. Distraction: listening to music, watch tv, writing or talking to friends Managing Delusions—do not whisper or laugh in the presence of the client. we must approach the patient with calmness, empathy, and gentle eye contact—do not touch the patient without warning. Trust must be developed—try to provide consistency in care and assigned care givers. Then we should use clear direct and simple statements. We should not go along with the delusions, as this can be very confusing to the patient. We should not attempt to logically explain the delusion to the patient as they are not able to process this during this time. Establish and maintain reality for the patient. Use distracting techniques, explain all procedures and interventions, including medication management.

Order the following nursing interventions used in the care of clients diagnosed with antisocial personality disorder A.Immediately set limits on manipulative behaviors that defy rules B.Review unit rules and regulations C.Consistently implement consequences of rule infractions D.Clearly explain the consequences of rule infractions

B, D, A, C

Personality disorders interventions

Basic level interventions -Milieu management: The goal of milieu therapy is affect management within a group context. Nurses must help patients verbalize feelings rather than act them out. -Pharmacological interventions: Patients with personality disorders my be helped by a broad array of psychotropic agents, all geared toward maintaining cognitive function and relieving symptoms. Antipsychotics may be useful for brief periods to control agitation, rage, and brief psychotic episodes. Medication compliance is usually an important issue; patients with PD are fearful about taking something over which they have no control. -Case management: Case management is geared toward reducing the necessity for hospitalization. Advanced practice interventions -Dialectical behavioral therapy (DBT): Dialectical behavior therapy (DBT) has shown favorable results with patients with personality disorders. It combines cognitive and behavioral techniques with mindfulness, which emphasizes being aware of thoughts and actively shaping them.

anger, aggression, and violence etiology

Biological factors -Areas of the brain -Neurotransmitters -Predisposition Psychological factors -Behavioral theory - learned response -Social learning theory - imitate others

schizophrenia alterations in Behavior

Bizarre behaviors take the form of stilted, rigid demeanor, eccentric dress or grooming, and rituals. Catatonia Motor retardation: slowing of movement Motor agitation: excited behavior Echopraxia Stereotyped behaviors: motor patterns that have become mechanical and purposeless. (sweeping the floor, washing windows) Waxy flexibility: when a client with schizophrenia allows body parts to be placed in bizarre or uncomfortable positions and then holds them there for long periods of time. (i.e. blood pressure) Negativism: Negativism—active negativism involves the patient doing the opposite of what is suggested; passive negativism involves not doing the things one is expected to do, such as getting out of bed, eating, and so forth. Impaired impulse control Boundary impairment Automatic obedience: the patient follows all simple commands in a robot like fashion. Agitated behavior: related to difficulty with impulse control; because of cognitive deterioration, patients lack social sensitivity and may act out impulsively.

Cluster B: Narcissistic

Characteristics -Pervasive pattern of grandiosity -Fantasies of brilliance or power -Need to be admired -Sense of entitlement -Disturbed relationships Strive for power and success----perfectionist standards—can be highly competitive Very labile relationships—if needs are not met, they may react with rage or shame (but may mask that outwardly) Can often be seen as arrogant, patronizing and rude Need to be admired—exaggerate their accomplishments and talents Sense of entitlement—expect to be seen and treated as special (even if they did nothing to deserve it) Disturbed relationships—unrealistic expectations of how they should be treated—friends are made by what the person can gain from the relationship and romantic partners are used to increase self esteem. Underlying self-esteem is almost always fragile and vulnerable; hypersensitive to criticism Nurse interventions: self awareness is key—r/t the nurse must not internalize the criticism they may receive ***stay neutral, avoid power struggles; Don't be defensive when disparaged; convey unassuming self-confidence —help clients identify attempts to seek perfection, exhibit grandiose behaviors and sense of entitlement

Anti-Social Personality Disorder

Characterized by a pattern of disregard for and violation of the rights of others---deceit and manipulation are key Normally appears before onset of 15—but until age 18, client is normally diagnosed with conduct disorder Superficial charm Deceitful, manipulative, aggressive Violates rights of others: lacks empathy—guilt and remorse Lies, cheats, exploits others Impulsive: acts out Exploits others—in a cold and calculating way while disregarding their feelings and rights At risk for substance abuse, criminal behaviors, and becoming victims of violence Nursing interventions: Promote responsible behavior-limit setting (let them know what they are and the consequences for crossing them); confronting (point out problem behavior and keep client focused on himself); teach client to solve problems effectively and manage emotions of anger or frustration

Criteria for Clusters

Cluster A -Odd or Eccentric Cluster B -Dramatic, Emotional, or Erratic Cluster C -Anxious or Fearful

schizophrenia interventions: redirecting socially inappropriate behaviors

Coping with socially inappropriate behaviors -Redirect -Matter of fact approach -Reintegrate into group as soon as possible May include touching us without warning or invitation, talking to or carassing inanimate objects, undressing in public----redirect, Coping with socially inappropriate behaviors—redirect client away from the problem situations Deal with inappropriate behavior in a non-judgmental matter of fact manner—do not scold. Do not make they feel punished or shamed for their behavior. Try to reintegrate into the social milieu as soon as possible.---clinical last week—man crawling on the floor licking it. Needed to be redirected by simple commands

personality disorders diagnosis, implementation

Diagnosis (Table 24-2) Outcomes identification (Table 24-3) Implementation -Safety and teamwork -Pharmacological interventions -Case management

Common Characteristics of Personality Disorders (PDs)

Difficulty in three areas of day-to-day functioning -Thoughts and emotions -Participation in interpersonal relationships -Managing impulses Personality disorders (PDs) involve long-term and repetitive use of maladaptive and often self-defeating behaviors. People with PDs do not recognize their symptoms as uncomfortable; thus they do not seek treatment unless a severe crisis occurs. All PDs have four characteristics in common: (1) inflexible and maladaptive response to stress; (2) disability in working and loving; (3) ability to evoke interpersonal conflict; (4) capacity to frustrate others. People with PDs tend to be perceived as aggravating and demanding by health care workers, so the potential for value judgments is high, and effective care is at risk.

schizophrenia interventions: managing loose associations

Do not pretend that you understand Place difficulty of understanding on yourself: let them know you don't know what they're saying. Clarify Look for reoccurring topics and themes Emphasize what is going on in the client's environment Involve client in simple, reality-based activities Reinforce clear communication of needs, feelings, and thoughts Loose associations mirror patient thoughts. Don't pretend to understand when you can't. Tell patient you're having difficulty understanding, placing the problem with yourself (i.e., "I'm having difficulty understanding what you're saying" instead of "You're not making sense"). Look for and mention recurring themes. (You mentioned trouble with your brother several times. Your relationship with your brother seems to be on your mind Emphasize what is going on in the environment, Emphasize the here and now. and involve the patient in simple reality-based activities. Tell patient when you do understand, reinforcing clear communication.--- Redirect and reinforce

Histrionic Personality Disorder

Dramatic presentation of self -all life is a stage—want to be the center of attention—good at acting out the role of the princess or victim (roller coaster) Excessive emotionality -to seek attention, love, admiration Overly concerned with impressing others: r/t their high need for approval----others experience this as smothering and destructive, Behaviors can be interpreted as coercive and attention seeking: constantly seek assurance, approval or praise nursing interventions—teach social skills; provide factual feedback about behavior Understand seductive behaviors as response to stress Keep relationship professional Teach and model assertiveness

Cluster B Personality Disorders

Dramatic, emotional, erratic behavior Problems with impulse control Examples -Antisocial PD -Borderline PD -Histrionic PD -Narcissistic PD

schizophrenia assessment

During the prepsychotic phase General assessment -Positive symptoms: usually occur first. are exaggerated or additional behaviors—hallucinations, delusions, disorganized speech (loose association) bizarre behavior)usually responsive to traditional antipsychotic meds. -Negative symptoms: are a loss or deficit of normal function. (blunted affect, poverty of speech, loss of motivation, anhedonia) These symptoms typically do not respond to the older or typical antipsychotics, but do respond better to the newer or atypical antipsychotics. -Cognitive symptoms: abnormalities in how a person thinks (inattention, impaired memory, poor problem solving skills, poor decision making, illogical thinking, impaired judgment.) -Affective symptoms: symptoms involving emotions and their expressions (dysphoria, suicidality, hopelessness) Nursing assessment focuses largely on symptoms, coping, functioning, and safety Schizophrenia symptoms are often categorized as Positive or Negative symptoms

Side effects of antipsychotics

EPS -Clinical Picture -Pseudoparkinsonism: Parkinson's like symptoms (pill rolling, tremors, mask like face, stooped posture, drooling)— -Akinesia: restlessnessx. muscular weakness "weak knees" -Akathisia: inner restlessness you can not resolve. Continuous restlessness or fidgeting. -Dystonia: involuntary muscular movements of spasms of face, arms, legs, and necks -Treatment: lower or stop all together. -S/E:Extrapyramidal effects such as dystonia, akathisia, and pseudoparkinsonism are treated by lowering dose and prescribing antiparkinsonian drugs such as trihexyphenidyl (Artane), benztropine (Cogentin), or diphenhydramine (Benadryl). -can have anticolinergic s/e Tardive Dyskinetia -Clinical Picture: involuntary movements (lip smacking, tongue protrusion, involuntary hand movements) -Treatment: no reliable treatment, stop the medication_ -Jerking movements. May or may not go away -STOP MEDICATION Tardive dyskinesia—involves involuntary tonic muscular spasms of the tongue, lips, fingers, toes, jaw, neck, trunk, and pelvis. The drugs must be discontinued, but no cure for TD exists. Assessment is performed using the Abnormal Involuntary Movement Scale. (SOFT TICS)

Cluster A Personality Disorders

Eccentric and odd behavior Unusual levels of suspiciousness Magical thinking Cognitive impairment Examples -Paranoid PD -Schizoid PD -Schizotypal PD

personality disorders evaluation

Evaluating treatment effectiveness in this patient population is difficult Short-term outcomes may be accomplished Patient can be given message of hope that quality of life can always be improved

atypical antipsychotics 3rd generation

Example: Aripiprazole (Abilify) Cloraril was the first to be developed---highly effective -Dopamine system stabilizer -Improves positive and negative symptoms and cognitive function Little risk of EPS or Tardive Dyskinesia "boosts" and used in conjunctive with other meds and disorders. Drawbacks— -serious s/e in a small percentage of patients -agranulocytosis -seizures The following meds do not cause agranulocytosis—are highly effective (first line choice of medications) Have a tendency to cause weight gain

Atypical antipsychotics 2nd generation

Examples Clozapine Quetiapine Risperidone Zipreasidone Olanzapine -Serotonin-dopamine antagonists -Treats both positive and negative symptoms Advantages -Less side effects (minimal to no EPS or Tardive dyskinesia) -Improves symptoms of depression and anxiety -Decreases suicidal behavior Disadvantages -Tendency to cause significant weight gain -Metabolic abnormalities ****First-Line Antipsychotics -Less side effects encourages medication compliance -Reduce disruptive/violent behaviors -Increase activity, speech, and socialization -Improve self care -Reduce hallucinations/delusions -Improve thought processes -Reduce relapse -Decrease paranoia ----------------------------only 10% fail to respond -Clients may be prescribed more than one of the newer antipsychotic meds for fuller symptom remission

typical antipsychotics: 1st generation

Examples: Haloperidol Thiothixene Fluphenazine Chlorpromazine -Dopamine antagonists (D1 receptor antagonsists) -Target positive symptoms of schizophrenia Advantage -Less expensive than atypical antipsychotics Disadvantages -Extra-pyramidal side effects (EPS) -Anticholinergic effects (ACH) -Tardive dyskinesia Most effective for positive symptoms (may worsen negative symptoms)

personality disorders epidemiology and comorbidity

Frequently co-occur with -Disorders of mood -Anxiety -Eating -Substance abuse Normally become apparent before or during adolescence and persist throughout the lifetime have a high degree of overlap In the general population, is 10% to 15%, depending on severity. Personality disorders are predisposing factors for many other psychiatric disorders and may coexist with depression, panic disorder, substance use disorder, eating disorder, anxiety disorder, PTSD, somatization, and impulse control disorders.

borderline personality disorder

Impulsive, unpredictable and manipulative: making relationships difficult self-mulilation, suicide threats, and attempted suicide are maladaptive responses to intense pain or attempts to relieve the sense of emptiness, or gain reassurance that they are alive and can feel pain-------often follow threats of separation from others, by rejection, or by demands of parenting or intimacy Self-mutilation Self-destructive behaviors -reckless driving, substance abuse, risky sexual practices, financial mismanagement Intense and unstable: ("Cyclical personality") difficulty managing anxiety Identity disturbance: self-evaluation can go between grandiose and deprecation—feel entitled and then unworthy Identity disturbance Nursing interventions: promote safety (assess for suicidal and self-mulilating behaviors)(no self-harm contract); help client to cope and control emotions (identify feelings, journal, delaying gratification) ; structure time; teach social skills; cognitive restructuring techniques (thought stopping, decatastophizing) Set clear, realistic goals Be aware of manipulative behaviors Clear, consistent boundaries/limits Avoid rejecting, rescuing Common co-occuring disorders -Mood disorders: (r/t chronic feeling of emptiness and changing emotions) -Substance disorders: (r/t risk taking behaviors) eating disorders (r/t the identity disturbance) -Eating disorders -PTSD: PTSD—most often r/t abuse -Frequent users of health and mental health resources: patterns of chronically moving from one crisis to another--don't normally see people with just PD in the hospital...no specific med to treat

anger, aggression, and violence epidemiology

In the hospital, violence is most frequent in -Psychiatric units -Emergency departments -Geriatric units

schizoid personality disorder

Inability to form personal relationships and connect to others in meaningful emotional ways Cold and indifferent to others Socially withdrawn and discomfort in human interaction: if occupation involves social interaction, may have issues—works best alone Would rather focus on intellectual pursuits rather then emotional ones. Focus on intellectual pursuits Childhood: characterized as cold, bleak, and notably lacking empathy and nurturing.—increased risk if child is shy, anxious, and introverted. Nursing interventions: improve clients functioning in the community; assist client to find case manager

anger, aggression, and violence nursing diagnoses

Ineffective coping Stress overload Risk for self-directed violence Risk for other-directed violence

schizophrenia interventions: managing hallucinations

Initial response: must determine what the client is experiencing Acknowledge fears while presenting reality Reality based activities Intervention requires knowledge of the content of the hallucinations. What are the voices saying/what is the patient seeing. (increases the nurses understanding and determines if voices are commanding pt. to do something. Acknowledge fears—I don't see anything, but you must be freighted. Reality based activities: playing cards, listening to music Speak loud, firm voice, call patient by name. Other strategies for patients with hallucinations—maintain eye contact, speak simply in a slightly louder voice than usual, call the patient by name and your book says use touch, but be careful with this as the patient may misinterpret this as a threat. Decrease external stimuli—loud noise, extremely bright colors, flashing lights, Use distraction

anger, aggression, and violence nursing self assessment

Knowledge of personal responses to anger and aggression -Choice of words -Tone of voice -Nonverbal communication -Personal triggers -Personal sense of competence Without self-knowledge, nurses are likely to make impulsive, emotion-based responses that are nontherapeutic and may be harmful The nurse's ability to intervene safely in situations of anger and violence depends on self-awareness. Nurses' responses to angry patients can escalate along a continuum similar to that of patients. The more a nursing intervention is prompted by emotion, the less likely it is to be therapeutic. The phenomenon of emotional contagion is explained. Nurses' responses reflect norms from their families of origin, personal issues, and situational events. In addition to self-assessment, techniques such as deep breathing, muscle relaxation, empathetic interpretation of patients' distress, and review of intervention strategies can be helpful.

schizophrenia interventions for the Maintenance and Stable Stage

Learn all you can about the illness. Develop a relapse prevention plan. Avoid alcohol and drugs. Learn ways to address fears and losses. Learn new ways of coping. Comply with treatment. Maintain communication with supportive people. Stay healthy by managing illness, sleep, and diet. Coping techniques for schizophrenia (client teaching) distraction, interaction, activity, social action, physical action Activities Provide support and structure Encourage development of social skills and friendships

schizophrenia epidemiology

Lifetime prevalence of schizophrenia 1% worldwide No difference related to -Race -Social status -Culture More common in males onset before the age of 10 has been reported. General: -Early onset -more with males (18-25) -Later onset—more with females (25-35) The later the onset the better the prognosis

What is schizophrenia?

Literal interpretation "Split mind" Split between the cognitive and emotional aspects of the personality. This does not mean split personality as if there are two different distinct personalities or identities. EFFECTS THE WAY A PERSON ACTS, THINKS, AND SEES THE WORLD. ALTERED PERCEPTION OF REALITY Splitting off of thoughts and emotions

schizophrenia cognitive symptoms

Looking at the area of COGNITION. Cognitive symptoms are one of the major disabilities associated with schizophrenia. Do not think of this as the patient is lacking in intelligence, as that is not the case. Often unable to produce complex logical thoughts & express coherent sentences Difficulty with -Attention: poor concentration, easily distractible, difficulty concentrating on work or completing task---person could be easily disturbed by external stimuli (someone passing in the hall, a door closing) or auditory hallucinations. -Memory: difficulty retrieving & using stored memory, impaired short term & long term memory. -Information processing -Cognitive flexibility -Executive functions: decision making, judgment, planning and problem solving These impairments are not constant and may fluctuate depending on the brain activity required and amount of external stimuli

anger, aggression, and violence outcomes identification

Maintains self-control without supervision Upholds contract to restrain aggressive behaviors

interventions: stabilization and maintenance phase

Medication administration/adherence Relationships with trusted care providers Community-based therapeutic services Phase II and III interventions include psychoeducation about the disease, medication, side-effect management, cognitive and social skills enhancement, identifying signs of relapse, and attention to self-care deficits. Stress minimization is of concern. Helping the patient reduce vulnerability to relapse will include providing information about maintaining a regular sleep pattern; reducing alcohol, drug, and caffeine intake; keeping in touch with supportive family and friends; staying active; having a daily or weekly schedule; and taking medication regularly. Attention should be given to patient strengths and healthy functioning.

schizophrenia other interventions for all stages

Milieu Management -Activities and groups -Safety Counseling and Communication Techniques -Hallucinations -Delusions -Associative looseness -Health teaching and health promotion Patients with schizophrenia improve more on a structured hospital unit rather than in an open environment. A therapeutic milieu provides safety, useful activities, resources for resolving conflicts, and opportunities for learning social and vocational skills. Activities and groups: During the acute phase, a structured milieu is more advantageous to the patient than the freedom of an open unit. Participation in activity groups decreases withdrawal, promotes motivation, modifies aggression, and increases social competence. Involvement in activity groups results in increased self-concept scores. Safety: In the acute phase, the risk for violence usually stems from hallucinations or delusions. Attempts should be made to use the least restrictive method of coping with violence (e.g., initially use verbal intervention, followed by medication, and lastly seclusion or restraint). Counseling and communication techniques: Be familiar with principles for dealing with hallucinations, delusions, and associative looseness. Use a nonthreatening and nonjudgmental manner. Speak simply, using a louder voice. Use patient's name. Box 15-3 identifies other strategies.

Assessment of personality disorders

Minnesota Multiphasic Personality Inventory (MMPI) to evaluate personality Full medical history Psychosocial history: all areas deal with different personality disorders -Suicidal or aggressive thoughts -Risk of harm from self or others -Use of medications or illegal substances -Ability to handle money -Legal history -Current or past abuse

Potentially Dangerous Responses to Antipsychotics: Rare and Toxic Effects

Neuroleptic malignant syndrome (NMS) -Abnormally high Temperature -Muscle rigidity -Elevated creatinine-kinase level -serious life threatening side effect. Hi fever, rigidity, elevated CPK -Symptoms develop over 24-72 hours and can last 1-40 days (ave: 10) -Supportive therapy: fever reduction, hydration and nutition medication therapy: Dantrolene—decrease body temp, relax peripheral muscles. Bromocriptine—decrease muscle rigidity Amandatine and levodopa-carbidopa—reduce hyperthermia Anticholinergic toxicity -dry mucous membranes, non reactive pupils, red skin, tachycardia, worsening psychotic symptoms, urinary retention, seizure, repetitive motor movements. hyperthermia Agranulocytosis**: low white blood cell count

personality disorders etiology

No single cause: most likely an interaction between biological factors and the environment Biological factors -Genetic: are thought to influence the development of personality disorders, but individual genes are not believed to be associated with particular personality traits. -Neurobiological Psychological factors: other diagnosis, ACEs -Learning theory, cognitive theories, and psychoanalytic theory may help to explain the development of personality disorders. Environmental factors -family relations (dysfunctional family can cause attachment issues)—(paranoid PD had parents who were excessively critical or who role modelede projection of anger and resentment on external groups.; avoidant personality disorder-parents who were over protective) not a sole factor as it can be offset by attachments to competent extended family members. Sociocultural factors—negative childhood experiences (lead to low self-esteem, negative self-concept, and even self-hatred.—hard to develop self-esteem and a healthy identity) Chronic trauma—person reacts out of past experience. Many people with personality disorders have a history of traumatic childhood events such as physical and sexual abuse

Effect of Clients with Personality Disorders on Caregivers

Overwhelming needs of clients may also be overwhelming for caregivers Caregivers may feel -Confused -Helpless -Angry -Frustrated

Obsessive Compulsive Personality Disorder

Perfection and inflexibility: checking and rechecking objects and situations demands much of their time Pack rat behavior, endlessly repeats tasks: don't like to throw things out -endlessly repeats tasks in effort to achieve perfection----Obsessions vs. Compulsions?---beliefs vs. acts Stubbornly insists on own way of doing things: Gives others directions-----complains about other inefficiencies Often are very industrial but not creative—fail to complete projects because of the unattainable standards they set for themselves---i.e. patient that got unset at work "I was going really well, but then they made breaks mandatory and I couldn't get things done." Superficial relationships: unable to express emotions—they need to feel in control to alleviate anxiety of helplessness and powerlessness OC personality disorder differs from OCD—Obsessive compulsive disorder is considered to be an ego-dystonic disorder, as the thoughts and compulsions experienced or expressed are not consistent with the individual's self-perception---behaviors, values, feelings, which are in harmony with or acceptable to the needs and goals of the ego, or consistent with one's ideal self-image—making it hard to treat They develop fears r/t an inability to manage anxiety—dread making mistakes—causes high level of guilt Nursing Interventions: encourage negotiations with others; assist client to make timely decisions and complete work; cognitive restructuring techniques

schizophrenia planning

Phase I - Acute -Best strategies to ensure patient safety and provide symptom stabilization Phase II - Stabilization Phase III - Maintenance -Provide patient and family education -Relapse prevention skills are vital Often requires hospitalization for stabilization. The treatment team will identify long-term care needs and identify and provide appropriate referrals for follow-up and support. Discharge planning must consider living arrangements, economic resources, social supports, family relationships, and vulnerability to stress 2 and 3 Foci include patient and family education, skills training, building relapse-prevention skills, and identifying needs for social, interpersonal, coping, and vocational skills.

Outcomes Identification

Phase I - Acute Patient safety and medical stabilization Phase II - Stabilization -Adhere to treatment -Stabilize medications -Control or cope with symptoms Phase III - Maintenance -Maintain achievement -Prevent relapse -Achieve independence, satisfactory quality of life. The acute phase essentially involves crisis intervention, with patient safety and medical stabilization as the overall goal. If the patient is at risk for violence to self or others, initial outcome criteria would address safety issues (i.e., "Patient will remain safe while hospitalized"). Another appropriate focus would be on outcomes that reflect improvement in intensity and frequency of hallucinations, delusions, and increasing ability to test reality accurately. Phase 2 and 3: Outcome criteria will focus on helping the patient to adhere to medication regimens, to understand the nature of the illness, and to participate in psychoeducational activities for patient and family. Maslow's hierarchy of needs

schizophrenia potential nursing diagnoses

Positive symptoms -Disturbed sensory perception -Impaired verbal communication -Risk for self-directed or other-directed violence Negative symptoms -Social isolation -Chronic low self-esteem Risk for self-directed or other-directed violence----need to assess for suicidal ideation and homicidal ideation—SI/HI Can't be r/t medical diagnosis-----r/t chemical imbalance secondary to schizophrenia Disturbed sensory perception (inaccurate interpretation of environmental stimuli) Disturbed thought processes (inappropriate non-reality based thinking) Impaired social interaction (r/t public outburst, personal hygiene, affect, etc)

anger, aggression, and violence comorbidities

Posttraumatic stress disorder (PTSD) Substance abuse disorders Coexists with -Depression -Anxiety -Psychosis -Personality disorders

Strategies/Interventions Cluster C

Provide problem solving and assertiveness training to increase self-confidence and independence Encourage expression of feelings to decrease rigidity and need for control Encourage clients to acknowledge and discuss a sense of inadequacy and/or fear of rejection Facilitate clients to recognize any impairment or distress r/t the need for perfection and control

schizophrenia interventions: acute phase

Psychiatric, medical, and neurological evaluation Psychopharmacological treatment Support, psychoeducation, and guidance Supervision and limit setting in the milieu When someone is switching meds they might have to be hospitalized.

schizophrenia evaluation

Relapse should not be interpreted as failure!! Important step!!!!!- allows for collection of new data and to reassess the patient's problems

Strategies/Interventions Cluster B

Remain patient in response to emotional, erratic, aggressive behavior Provide a consistent and structured milieu to avoid manipulation and power struggles Protect clients from suicide and self-mutilation until they can protect themselves If client self-mutiliates, treat wounds in a matter-of-fact manner Set limits Engage in frequent staff conferences to counteract splitting Encourage direct communication to minimize attention seeking through use of dramatic, seductive behaviors Role-model healthy behaviors and effective communication

Coping disorders used by patients with personality disorders

Repression Suppression Regression Projection: places responsibility for antisocial behavior outside oneself. Blaming—the problem are the police they have it in for me. Splitting: A major defense mechanism used by the these clients is SPLITTING- failure to integrate the positive and negative qualities of self or others. They idealize others (staff, friends), but then quickly may shift despising the other person if their needs were not met. They also may split staff—one staff may be the "good nurse" where the other nurse is the "bad nurse". You do not want to get caught up in this. First of all do not feel too good even if you are the "good one" as that can change on a moments notice.

schizophrenia etiology

Schizophrenia most likely occurs as a result of a combination of factors including: genetic and nongenetic factors (e.g., viral infection, birth injuries, nutritional factors). Biological factors Genetics -do see a genetic link but no single gene has been identified. Having a first degree relative increased your risk nearly 10%. Neurobiological Dopamine theory -things that increase levels of dopamine (amphetamines, cocaine, THC, etc...may precipitate schizophrenias onset in someone biologically susceptible. Other neurochemical hypotheses -Dopamine and serotonin hypothesis---increased level of the neurochemicals.......when we look at the medications, they block the receptors of the dopamine/serotonin pathways—not conclusive Brain structure abnormalities -Neuroanatomical—venticles are larger—normal brain shows more activity in the frontal cortex-----the fluid filled ventricles can push on the frontal cortex Psychological and environmental factors Prenatal stressors -viral infections (HSV2) , poor nutrition, hypoxia, and exposure to toxins; psychological trauma to mother; father older than 35-being born late winter or early spring. EARLY CAUSES. OBSTRECTIC PROBLEMS. Psychological stressors -(stress increases cortisol levels—impedes hypothalamic development) a break in a person susceptible to the illness Environmental stressors -toxins contributes to the development in vulnerable populations: chronic poverty, high crime environments. IDEA THAT IT'S NOT JUST ONE THING THAT CONTRIBUTES TO THE DEVELOPMENT OF THE ILLNESS Stress: may precipitate the illness in vulnerable individual Precipitating stressors: It is important for patients with schizophrenia to recognize their triggers (stressors or events that will likely set off their symptoms). They need to be taught how to avoid them if possible or contact their mental health professional for help if they cannot. Triggers may include: Health—poor nutrition, lack of sleep, infection, CNS drugs(depressants/slows them down), lack of exercise, barriers to health care Environment—housing problems, change in life events, lack of social support, job pressures Attitudes/behaviors—hopeless, lack of control, poor self esteem, poor medication management, poor symptom management

Dependent Personality Disorder

Sense of being incapable of survival if left alone Fears are excessive, extreme, persistent and not amenable to logic Incapable of making daily decisions without advice and reassurance: lack self-confidence Anxious and helpless when alone (desire constant companionship), submissive: Volunteer to do unpleasant and demeaning things to increase their chance of acceptance Fears rejection and abandonment Go to great lengths not to be alone and may agree with others to avoid rejection. Nursing interventions: foster client's self-reliance and autonomy; teach problem-solving and decision making skills (not the same as giving advice); cognitive restructuring techniques (reframing and decatastrophizing—"I can't do anything right..." how could you challenge that belief?

schizophrenia behaviors: behaviors leading to relationship development dysfunction

Social inappropriateness Inappropriate sexual behavior Stigma related withdrawal by friends, families, peers

Avoidant Personality Disorder

Social inhibition or discomfort (fearful and shy)—reluctant to get involved in relationships without guarantee of uncritical acceptance (few social contacts)---avoids jobs that involves significant interpersonal contact (r/t fears) Preoccupation with fear of rejection: may perceive rejection where none exists—idea that "if people get close to me, they will discover the real me and reject me." Overly sensitive to criticism: sensitive to the opinions of others (exaggerated need for acceptance) Fearful own self doubts will be seen by others Reluctant to take personal risks: fear of being embarrassment by blushing, tears, tears or showing signs of anxiety to other people Nursing interventions: support and reassurance; cognitive restructuring techniques; promote self-esteem (help them explore positive self-aspects, positive responses from others and possible reasons for self-criticism.---self affirmations and positive self-talk

schizophrenia comorbidity

Substance abuse disorders: 50% of individuals with schizophrenia----associated with nonadherence to treatment, relapse, incarceration, homelessness, violence, suicide and poorer prognosis -Nicotine dependence (calming): 70-90% associated with heart and lung disease Anxiety, Depression, and suicide: many occur during remission (after 5-10 years of the illness) Anxiety, depression, and suicide -suicide: not wanting to live with the signs and symptoms Physical health or illness Polydipsia -Psychosis-induced polydipsia: (compulsive drinking of 4-10 liters/day) 8 -8oz glasses equal 1.8 liters can gain 5-15 pounds from a.m. to afternoon hyponatremia---headache, confusion, hostility, and can lead to seizure and death cause: (?) anti-cholinergic effect of meds, compulsive behaviors, hypothalamus dysfunction

Phases of Schizophrenia

The course of the disease usually involves recurrent acute exacerbations of psychosis. It can be presented in three phases: the acute phase, the stabilization phase and the maintenance phase. Recurrent acute exacerbations of psychosis Increase in residual dysfunction and deterioration with each relapse Phase I - Acute -Onset or exacerbation of symptoms Phase II - Stabilization -Symptoms diminishing -Movement towards previous level of functioning Phase III - Maintenance -At or near baseline functioning

Compliance Issues with antipsychotics

Undesirable S/E Prescription accessibility: cost...going out to get them Social pressure: (reminder that your sick) (antipsychotic—if I said I was on one what would you think) Difficulty keeping appointments: trusting providers Complicated medication schedules: certain antipsycotics—haldol, prolixin, risperdal---decanoate

A patient with schizophrenia says, "There are worms under my skin eating the hair follicles." How would you classify this assessment finding? a.Positive symptom b.Negative symptom c.Cognitive symptom d.Depressive symptom

a

According to psychoanalytic theory, which is the best description of the id? A.Seeks instant gratification B.Represents mature and adaptive behavior C.Reflects moral and ethical concepts and values

a

The nurse is teaching a client about the neuroleptic medication she is now taking. While discussing extrapyramidal side effects associated with these medications, what will the nurse include in the discussion? A.The medications are sometimes associated with restlessness, stiffness, and drooling. B.The medications cause a dry mouth C.The medications are associated with constipation D.The medications cause blurred vision

a

An instructor is teaching students about clients diagnosed with BPD. Which of the following student statements indicate(s) that further instruction is needed? (select all that apply) A."Individuals consider relationships to be more intimate than they actually are" B."Individuals always seen to be in a state of crisis" C."Individuals read hidden threatening meaning into benign remarks" D."Individuals have little tolerance for being alone and have chronic fear of abandonment" E."Individuals manifest an inability to integrate and accept both positive and negative feelings."

a,c

A client is being assessed for schizotypal personality disorder. Which of the following behaviors would the nurse expect to note? (Select all that apply) A.The client experiences magical thinking and ideas of reference B.The client has an intense fear of making mistakes, leading to difficulty with decision making C.Under stress, the client may decompensate and demonstrate various psychotic behaviors D.The client is extremely vulnerable and constantly on the defensive E.The client is aloof and may have an affect that is bland or inappropriate

a,c,e

Which of the following are negative symptoms of schizophrenia that are categorized as psychomotor behavior? Select all that apply. A.Anergia B.Apathy C.Waxy flexibility D.Emotional ambivalence E.Posturing

a,c,e

A client has been adherent with olanzapine 4 mg at HS for the past year. On assessment, the nurse notes that the client has bizarre facial and tongue movements. Which is a priority nursing intervention? A.With the next dose of olanzapine, give the ordered prn dose of bentropine B.Notify the physician of the observed side effects, place a hold on the Olanzapine, and request discontinuation of the medication C.Ask the physician to increase the dose of Olanzapine to assist with the bizarre movements. D.Explain to the client that the side effects are temporary and should subside in 2-3 weeks.

b

An adult with paranoia becomes agitated and threatens to assault a staff person. Select the best initial nursing intervention. a.Tell the patient, "If you do not calm down, seclusion will be needed." b.Address the patient with simple directions and a calming voice. c.Help the patient focus by rubbing the patient's shoulders. d.Offer the patient a dose of antipsychotic medication. e.Reorient the patient to the time and place.

b

Tardive dyskinesia sometimes occurs in response to neuroleptics. What will the nurse teach the client about tardive dyskinesia (TD)? A.The symptoms of TD are completely reversible B.The symptoms of TD are irreversible C.The symptoms of TD improve when the body becomes accustomed to the neuroleptic

b

The client diagnosed with schizophrenia says, "Everyone here is part of the secret police and wants to torture me," and he refuses to be weighed by a member of the nursing staff. What is the most appropriate response by the nurse? A."That is a strange idea. We aren't secret police persons." B."That must be a frightening thought. We are nurses who work at the hospital." C."Being suspicious isn't easy, is it? You won't be tortured here." D."There is no need to be frightened. We will keep you safe from torture."

b

The nurse asks the client to interpret the following, "people in glass houses shouldn't throw stones." The client responds, "the house will break." This is an example of a.abstraction b.concrete thinking c.echopraxia d.hallucinations

b

The nurse is caring for a client with antisocial PD. The client tells the nurse he will not be making his bed this morning because he has a visitor coming and he needs the time to get ready. What is the nurse's best response? A."Ok. I know you want to look nice for your visitor." B."All clients must tidy their room each morning. That is one of the rules." C."Your visitor may see your room; you don't want it to be messy." D."You must straighten your room like all the other clients. Do you think you are better than everyone else?"

b

When working with a client with a schizoid PD, which approach should the nurse plan to use when interacting with this client? A.Helpful and nurturing B.Matter-of-fact and calm C.Light and playful D.Warm and friendly

b

A client is admitted to the unit with a diagnosis of PD. The client is withdrawn and refuses to go to group. In addition, the client acts very fearful when approached by staff. The nurse considers that this behavior is consistent with which type of PD. Select all that apply. A.Antisocial PD B.Avoidant PD C.Histrionic PD D.Dependent PD E.Obsessive compulsive PD

b,c,e

A client diagnosed with schizophrenia says, "I want to go home to tome in a dome." When documenting, the nurse will refer to this as which of the following? A.Echopraxia B.Echolalia C.Clang associations D.Associative looseness

c

A client diagnoses with schizophrenia tells the nurse that another client is "creating negative thoughts in me against my will." The nurse documents that the client is exhibiting which of the following features of schizophrenia? A.Thought broadcasting B.Thought blocking C.Thought insertion D.Thought control

c

A client says, "I don't remember what happened during the accident." What defense mechanism is the client using to protect the client's conscious awareness from the trauma of the event? A.Denial B.Repression C.Suppression

c

A client states, "I can't go in the bathroom because I saw a demon in the tub." Which nursing diagnosis reflects this client's problem? A.Self-care deficit B.Ineffective health maintenance C.Disturbed sensory perception D.Disturbed thought process

c

A client taking antipsychotic medications for treatment of schizophrenia reports feeling nervous. The nurse notices that the client is pacing the long hallway and is unable to remain still, even when in conversation with the client. What term should the nurse use to document the occurrence? A.Dystonia B.Akinesia C.Akathisia D.Tardive dyskinesia

c

The mental health nurse is reviewing a 35 y.o. client's history before conducting an interview. The client's history indicates fear of criticism and rejection from others, having few friends, and withholding information about thoughts and feelings in anticipation of rejection from others. Based on the data, the nurse suspects that the client may have which PD? A.Schizotypal B.Paranoid C.Avoidant D.Schizoid

c

Which behavior indicates that a patient diagnosed with borderline personality disorder is improving? a.The patient cries when her roommate refuses to go to the dining room with her. b.The patient yells at the group facilitator when he points out she is monopolizing the group. c.The patient informs staff that she feels unsafe and is having thoughts of harming herself. d.The patient tells the evening staff that the day staff excused her from group to smoke when she got upset.

c

The client hears the word match. The client says, "A match. Tomorrow is the end of the world. Nothing is better than hot coffee." Which communication pattern does the nurse identify? A.Word salad B.Clang Association C.Loose Association D.Ideas of Reference

c Word salad is a group of words put together randomly without any logical connection. The situation in the question demonstrates a connection between words and phrases verbalized by the client. Clang association is a grouping of words without any logical connection that sound alike. An example of clang association is the following: "It is true. I am blue. They really should have glue." The situation in the question does not demonstrate a rhyming clang association. Loose association is characterized by communication in which ideas shift from one unrelated topic to another. The situation in the question clearly represents this communication pattern. Ideas of reference is the delusional belief that one is being talked about by others. In the situation in the question, the client does not demonstrate any delusional belief of being talked about.

A client is planning to be discharged from the hospital. It is the nurse's responsibility to educate this client regarding prescribed medications. This client is taking Clozapine (Clozaril). The nurse makes it a priority to teach the client to notify the MD immediately for which of the following? A.Feelings of increased energy and interest in the environment B.Unusual reactions to exposure to the sun C.Interferences with the normal sleep pattern D.Indications of any sort of infection

d

A nurse would recognize which medication as most effective in providing a client immediate relief from extrapyramidal side effects? A.Lorazepam 1 mg PO B.Diazepam 5 mg PO C.Haloperidol 2 mg IM D.Benztropine 2 mg PO

d

To deal with the clients hallucinations in a therapeutic way, which nursing intervention should be implemented? A.Reinforce the perceptual distortions until the client develops new defenses B.Provide an unstructured environment C.Avoid making connections between anxious situations and hallucinations D.Distract the clients attention

d

A client is experiencing paranoid delusions. What behaviors could the nurse expect to assess? A.Altered speech and extreme suspiciousness B.Psychomotor retardation C.Regressive and primitive behaviors D.Anger and aggressive acts

d A is wrong as although thoughts are disorganized during paranoia, speech is rarely altered

The nurse is caring for a 19-year-old client with her 1st psychotic episode. She has been diagnosed with paranoid schizophrenia and is admitted to the acute psychiatric unit. She tells the nurse she hears voices that give her important information. How should the nurse proceed? a.Brush her hair since she isn't taking care of her physical needs. b.Tell the client not to listen and join the others in the activity room. c.Tell the client there are no voices. d.Ask the client what the voices are saying.

d Is there suicidal idealation? Homicidal? Safety.

DSM schizophrenia criteria

page 193 in Varcarolis