Scitzophrenia
If a patient has EPS what would you find in your prn orders?
Benadryl or cogentin
Select the outcomes most appropriate for a client in phase III of treatment of schizophrenia who displays many negative symptoms of the disorder. The client will (more than one answer may be correct) A. take medication as ordered. B. maintain a regular sleep pattern. C. use alcohol and caffeine as desired. D. participate in self-care skills training.
ANS: A, B, D Rationale: The stabilization phase of schizophrenia is seen when the client is well enough to be maintained in the community. It is a time for consolidating gains, learning relapse prevention (options A and B), and promoting adaptation to deficits that still exist (option D). Option C: Use of alcohol, caffeine, and other recreational drugs should be discouraged because these substances interfere with therapeutic medication effects. DIF: Cognitive Level: Application REF: Text Page: 398 TOP: Nursing Process: Planning (Outcome Identification) MSC: NCLEX: Psychosocial Integrity
A client standing in the dining room is experiencing auditory hallucinations commanding him to strangle someone. His behavior and verbalizations indicate he is experiencing severe to panic level anxiety. Put each of the nursing interventions in the order they should be undertaken. A. Send another staff member to report the situation and obtain a prn medication. B. Assure the client that staff will help him resist the command. C. Take the client to a quiet, secure environment. D. Clear the dining room of other clients. E. Explain that the medication will stop the voices, then administer the drug.
ANS: B, D, A, C, E Rationale: This sequence supports client self-control to resist the command, protects other clients from potential harm, secures help from another while allowing the nurse to remain with the client to provide structure and set limits, removes client to a safer, less confusing environment, explains therapeutic use of medication, and limits the possibility of the client perceiving the medication as punishment. DIF: Cognitive Level: Analysis REF: Text Page: N/A TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment;
A client with schizophrenia begins to talk about "volmers" hiding in the warehouse where he works and undoing his work each night. The term "volmers" should be assessed as a. a neologism. b. concrete thinking. c. thought insertion. d. an idea of reference.
ANS: A A neologism is a newly coined word having special meaning to the client. "Volmer" is not a known word. Option B: Concrete thinking refers to the inability to think abstractly. Option C: Thought insertion refers to the idea that the thoughts of others are being planted in one's mind. Option D: Ideas of reference are a type of delusion in which trivial events are given personal significance. DIF: Cognitive Level: Application REF: Text Page: 392, Text Page: 393 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
A client with many positive symptoms of schizophrenia whose behavior is disorganized and who is highly anxious tells the nurse in the psychiatric emergency department "You have got to help me. I do not know what is going on. I think someone is trying to wipe me out. I have to get a gun." The client, a college student, lives alone and has no family or support system in the immediate area. He has not left his room in 2 weeks, has not eaten in several days, and is unkempt. Of the available treatment settings, the nurse should recommend a. acute hospitalization for 4 to 5 days. b. partial hospitalization for 2 weeks. c. day treatment for 4 weeks. d. home treatment for 6 weeks.
ANS: A A short-term hospital stay would probably serve the client best. Medication can be started, the inpatient milieu can provide structure, observation can be ongoing, interpersonal support can be provided, physical needs can be met, and the safety of client and others preserved. The client has no support system to provide care at home, and both partial hospitalization and day treatment would leave the client without structure and support for at least 12 hours daily. DIF: Cognitive Level: Analysis REF: Text Page: 399, Text Page: 400 TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment
A client with schizophrenia is admitted to the psychiatric unit in an acutely disturbed, violent state. He is given several doses of haloperidol (Haldol) and becomes calm and approachable. During rounds, the nurse notices the client has his head rotated to one side in a stiffly fixed position. His lower jaw is thrust forward and he is drooling. He appears severely anxious. The client has a. a dystonic reaction. b. tardive dyskinesia. c. waxy flexibility. d. akathisia.
ANS: A Acute dystonic reactions involve painful contractions of the tongue, face, neck, and back. Opisthotonos and oculogyric crisis may be observed. Dystonic reactions are considered emergencies requiring immediate intervention. Option B: Tardive dyskinesia involves involuntary spasmodic muscular contractions that involve the tongue, fingers, toes, neck, trunk, or pelvis. It appears after prolonged treatment. Option C: Waxy flexibility is a symptom seen in catatonic schizophrenia. Option D: Akathisia is evidenced by internal and external restlessness, pacing, and fidgeting. DIF: Cognitive Level: Analysis REF: Text Page: 405, Text Page: 406, Text Page: 407, Text Page: 408, Text Page: 409, Text Page: 410, Text Page: 411 TOP: Nursing Process: Assessment MSC: NCLEX: Physiologic Integrity
A client is admitted to the in-patient unit in the withdrawn phase of catatonic schizophrenia. He is completely stuporous. While giving care to the client, the nurse must a. explain care activities in simple, explicit terms as though expecting a response. b. maintain a quiet, nonstimulating atmosphere, speaking as little as possible to the client. c. provide high levels of sensory stimulation by using conversation, the radio, and television. d. address negativism by asking the client to do exactly the opposite of what is desired.
ANS: A Although the withdrawn, catatonic client may appear stuporous, he may be aware of everything going on around him. The client should be treated as though he can see and hear and as though he will respond normally. Option B: The client needs contact with the nurse on a frequent basis. Option C: Excessive auditory stimulation can be a disorganizing influence. Option D: This is nontherapeutic. DIF: Cognitive Level: Application REF: Text Page: 414 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment;
Family members of a client newly diagnosed with paranoid schizophrenia state that they do not understand what caused the client's illness. The nurse's response should be predicated on the a. neurobiological-genetic model. b. stress model. c. family theory model. d. developmental model.
ANS: A Compelling evidence exists that schizophrenia is a neurological disorder probably related to neurochemical abnormalities, neuroanatomical disruption of brain circuits, and genetic vulnerability. Options B, C, and D: Stress, family disruption, and developmental influences may contribute but are not considered single etiologies. DIF: Cognitive Level: Application REF: Text Page: 386, Text Page: 387 TOP: Nursing Process: Implementation MSC: NCLEX: Physiologic Integrity
A client was admitted to the mental health unit after arguing with co-workers and threatening to kill them. He is diagnosed with paranoid schizophrenia. On the unit he is aloof and suspicious. He mentioned that two physicians he saw talking were plotting to kill him. On the basis of data gathered at this point, two nursing diagnoses the nurse should consider are a. disturbed thought processes and risk for other-directed violence. b. spiritual distress and social isolation. c. risk for loneliness and deficient knowledge. d. disturbed personal identity and noncompliance.
ANS: A Delusions of persecution and ideas of reference support a nursing diagnosis of disturbed thought processes. Risk for other-directed violence is substantiated by the client's feeling endangered by persecutors. Fearful individuals may strike out at perceived persecutors or may attempt self-harm to get away from persecutors. Data are not present to support the diagnoses in the other options. DIF: Cognitive Level: Analysis REF: Text Page: 396, Text Page: 397 TOP: Nursing Process: Nursing Diagnosis MSC: NCLEX: Psychosocial Integrity
The nurse who observes a client prescribed haloperidol who has his head rotated to one side in a stiff, fixed position with his lower jaw thrust forward and drool coming from his mouth should intervene by a. obtaining an order to administer diphenhydramine (Benadryl) 50 mg IM. b. reassuring the client that the symptoms will subside if he relaxes. c. administering trihexyphenidyl (Artane) 5 mg orally. d. administering atropine 2 mg subcutaneously.
ANS: A Diphenhydramine, trihexyphenidyl, benztropine, and other anticholinergic medications may be used to treat dystonias, but because the client is drooling the nurse must assume swallowing is difficult, if not impossible. Therefore oral medication is not an option. Medication should be administered intramuscularly. In this case the option given is diphenhydramine. DIF: Cognitive Level: Application REF: Text Page: 409 TOP: Nursing Process: Implementation MSC: NCLEX: Physiologic Integrity
A newly admitted client diagnosed with paranoid schizophrenia is hypervigilant and constantly scans the environment. He states that he saw two doctors talking in the hall and knows they were plotting to kill him. The nurse may correctly assess this behavior as a. an idea of reference. b. a delusion of infidelity. c. an auditory hallucination. d. echolalia.
ANS: A Ideas of reference are misinterpretations of the verbalizations or actions of others that give special personal meanings to these behaviors; for example, seeing two people talking, the individual assumes they are talking about him or her. The other behaviors do not correspond with the scenario. DIF: Cognitive Level: Application REF: Text Page: 392 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
The nurse spends several sessions with a client with paranoid schizophrenia and the client's family to help them understand the importance of the client regularly taking antipsychotic medication. The client repeatedly states he does not like taking pills, and family members say they feel helpless to foster his compliance. The treatment strategy the nurse should discuss with the physician is a. use of an antipsychotic decanoate preparation. b. adjunctive use of amitriptyline (Elavil). c. use of benzodiazepines such as diazepam (Valium). d. use of chlordiazepoxide (Librium).
ANS: A Medications such as fluphenazine decanoate and haloperidol decanoate are long-acting forms of antipsychotic medication. They are given by depot injection every 2 to 4 weeks, thus reducing daily opportunities for noncompliance. The other options do not address the client's dislike of taking pills. DIF: Cognitive Level: Application REF: Text Page: 407 TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment;
The wife of a client with schizophrenia is worried about her 17-year-old daughter and asks the nurse what symptoms mark the prodromal stage of schizophrenia. The nurse should respond by listing behaviors such as a. withdrawal, misinterpreting, poor concentration, and preoccupation with religion. b. auditory hallucinations, ideas of reference, thought insertion, and broadcasting. c. stereotyped behavior, echopraxia, echolalia, and waxy flexibility. d. loose associations, concrete thinking, and echolalia neologisms.
ANS: A Options B, C, and D each list the positive symptoms of schizophrenia that might be apparent during the acute stage of the illness. Prodromal symptoms, the symptoms that are present before the development of florid symptoms, are listed in option 1. DIF: Cognitive Level: Application REF: Text Page: 389 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance
A client with catatonic schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. The client's needs of priority importance are a. physical. b. psychosocial. c. safety and security. d. self-actualization.
ANS: A Physical needs must be met to preserve life. A client who is semistuporous must be fed by hand or tube, toileted, given range-of-motion exercises, and so forth to preserve physiological integrity. Safety needs rank second to physical needs. Higher level needs are of lesser concern. DIF: Cognitive Level: Analysis REF: Text Page: 414 TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment
To establish a relationship with a severely withdrawn schizophrenic client being cared for at home by a supportive family, the most realistic plan would be for the community mental health nurse to a. visit daily for 4 days, then every other day for 1 week; stay with client for 20 minutes, accept silence; state when the nurse will return. b. arrange to spend 1 hour each day with the client, with the focus on asking questions about what the client is thinking or experiencing; avoid silences. c. visit twice daily; sit beside the client with hand on the client's arm; leave if the client does not respond within 10 minutes. d. visit every other day; remind the client of the nurse's identity; tell the client he may use the time to talk or the nurse will work on reports.
ANS: A Severe constraints on the community mental health nurse's time will probably not allow more time than what is mentioned in option A, yet important principles can be used. A severely withdrawn client should be met "at the client's own level," with silence accepted. Short periods of contact are helpful to minimize both the client's and the nurse's anxiety. Predictability in returning as stated will help build trust. Option B: An hour may be too long to sustain a home visit with a withdrawn client, especially if the nurse persists in leveling a barrage of questions at the client. Option C: Twice-daily visits are probably not possible, and leaving after 10 minutes would be premature. Touch may be threatening. Option D: Working on reports suggests the nurse is not interested in the client. DIF: Cognitive Level: Application REF: Text Page: 399, Text Page: 400 TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment
The family of a client with acute symptoms of schizophrenia knows nothing about the client's illness and the role the family can play in his recovery. The nurse should recommend that they attend a. psychoanalytic group therapy. b. a psychoeducational group. c. transactional therapy. d. family therapy.
ANS: B A psychoeducational group explores the causes of schizophrenia, the role of medication, the importance of medication compliance, support for the ill member, and hints for living with a schizophrenic person. Such a group can be of immeasurable practical assistance to the family. The other types of therapy do not focus on psychoeducation. DIF: Cognitive Level: Application REF: Text Page: 402, Text Page: 403 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance
Which client with schizophrenia would be expected to have the lowest score in global assessment of functioning? a. Client A, aged 39 years, who had paranoid ideation develop at age 35 years b. Client B, aged 40 years, who has had disorganized schizophrenia since age 18 years c. Client C, diagnosed as catatonic at age 24 years, who has been stable for 3 years d. Client D, aged 19 years, diagnosed with undifferentiated schizophrenia at age 17 years
ANS: B Disorganized schizophrenia represents the most regressed and socially impaired of all the schizophrenias. Client B could logically be expected to have the lowest global assessment of functioning. In addition, the client has been ill for a number of years. Option A: Client A could be expected to have the highest score because paranoid schizophrenia of short duration may be less impairing than other types. Option C: Client C has been stable more than 3 years, suggesting higher functional ability. Option D: Client D has been ill only 2 years, and disability in undifferentiated schizophrenia remains fairly stable over time. DIF: Cognitive Level: Application REF: Text Page: 412, Text Page: 414, Text Page: 415, Text Page: 416 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
A client with schizophrenia has received standard antipsychotics for a year. His hallucinations are less intrusive, but the client remains apathetic, has poverty of thought, cannot work, and is socially isolated. To address these symptoms, the nurse might expect the psychiatrist to prescribe a. haloperidol (Haldol). b. olanzapine (Zyprexa). c. diphenhydramine (Benadryl). d. chlorpromazine (Thorazine).
ANS: B Olanzapine is an atypical antipsychotic that targets both positive and negative symptoms of schizophrenia. Options A and D are standard antipsychotics that target only positive symptoms. Option C is an antihistamine. DIF: Cognitive Level: Application REF: Text Page: 405 TOP: Nursing Process: Planning MSC: NCLEX: Physiologic Integrity
Which findings listed in the medical record of a client with schizophrenia indicate a neurological origin for schizophrenia? a. A hostile, overinvolved parent and a weak, uninvolved parent b. Enlarged or asymmetrical ventricles, cortical atrophy c. Presence of ambivalence and flattened affect d. Presence of delusions and hallucinations
ANS: B Only option B relates to neurological findings. Options C and D refer to symptoms. Option A refers to family dynamics. DIF: Cognitive Level: Analysis REF: Text Page: 387 TOP: Nursing Process: Assessment MSC: NCLEX: Physiologic Integrity
A client with catatonic schizophrenia is semistuporous, demonstrating little spontaneous movement and waxy flexibility. The client's self-care activities of daily living have been assessed as severely compromised. An appropriate outcome would be that the client will a. demonstrate increased interest in the environment by the end of week 1. b. perform self-care activities with coaching by the end of week 1. c. gradually assume the initiative in self-care by the end of week 2. d. accept tube feeding without objection by day 2.
ANS: B Outcomes related to self-care deficit nursing diagnoses should deal with increasing ability to perform self-care tasks independently, such as feeding, bathing, dressing, and toileting. Performing the tasks with coaching by nursing staff denotes improvement over the complete inability to perform the tasks. Option A is not directly related to self-care activities. Option C is difficult to measure. Option D is related to maintenance of nutrition. DIF: Cognitive Level: Application REF: Text Page: 414 TOP: Nursing Process: Planning (Outcome Identification) MSC: NCLEX: Psychosocial Integrity
When a client diagnosed with paranoid schizophrenia was discharged from the unit 6 months ago, the plan was for him to take chlorpromazine (Thorazine) 300 mg po daily. He tells the nurse he stopped taking his pills after a few months because they made him feel like a "zombie." The common side effects the nurse should validate with the client include a. sweating, nausea, and diarrhea. b. sedation and muscle stiffness. c. headache, watery eyes, and runny nose. d. mild fever, sore throat, and skin rash.
ANS: B Phenothiazines often produce sedation and extrapyramidal side effects such as stiffness and gait disturbance, effects the client might describe as making him feel like a "zombie." The side effects mentioned in the other options are usually not associated with phenothiazine therapy or would not have the effect described by the client. DIF: Cognitive Level: Application REF: Text Page: 405, Text Page: 407 TOP: Nursing Process: Assessment MSC: NCLEX: Physiologic Integrity
A client with schizophrenia who has received chlorpromazine (Thorazine) 200 mg po 4 times daily for 3 weeks has symptoms of a shuffling, propulsive gait, a masklike face, and drooling. These symptoms should be assessed as a. hepatocellular effects. b. pseudoparkinsonism. c. tardive dyskinesia. d. akathisia.
ANS: B Pseudoparkinsonism induced by antipsychotic medication mimics the symptoms of Parkinson's disease. It frequently appears within the first month of treatment. Hepatocellular effects would produce abnormal liver test results. Tardive dyskinesia produces involuntary tonic muscular spasms. Akathisia produces symptoms of motor restlessness. DIF: Cognitive Level: Application REF: Text Page: 405, Text Page: 406, Text Page: 407, Text Page: 408, Text Page: 409, Text Page: 410, Text Page: 411 TOP: Nursing Process: Assessment MSC: NCLEX: Physiologic Integrity
A client received maintenance doses of trifluoperazine (Stelazine) 30 mg po daily for 1.5 years. The clinic nurse notes the client is grimacing and seems to be constantly smacking her lips. Her neck and shoulders twist in a slow, snakelike motion. The nurse should suspect the presence of a. agranulocytosis. b. tardive dyskinesia. c. Tourette's syndrome. d. anticholinergic effects.
ANS: B Tardive dyskinesia is a neuroleptic-induced condition involving the face, trunk, and limbs. Involuntary movements such as tongue thrusting; licking; blowing; irregular movements of the arms, neck, and shoulders; rocking; hip jerks; and pelvic thrusts are seen. These symptoms are frequently not reversible even when the drug is discontinued. The scenario does not present evidence consistent with the other disorders mentioned. Option A: Agranulocytosis is a blood disorder. Option C: Tourette's syndrome is a condition in which tics are present. Option D: Anticholinergic effects include dry mouth, blurred vision, flushing, constipation, and dry eyes. DIF: Cognitive Level: Application REF: Text Page: 409 TOP: Nursing Process: Assessment MSC: NCLEX: Physiologic Integrity
A newly admitted client diagnosed with paranoid schizophrenia believes co-workers are "out to get" him and has stated he thinks two doctors on the unit are plotting to kill him. How does the client perceive the environment? a. Supportive b. Dangerous c. Disorganized d. Bizarre
ANS: B The client sees his world as hostile and dangerous. This assessment is important because the nurse can be more effective by using empathy to respond to the client. Data are not present to support any of the other options. DIF: Cognitive Level: Analysis REF: Text Page: 392 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
A catatonic client admitted in a stuporous condition begins to demonstrate increased motor activity. He sometimes walks slowly around the unit without interacting. One day the nurse observes him standing immobile, facing the wall with one arm bent behind his back and the other extended in a Nazi-like salute. He remains immobile in that position for 15 minutes, moving only when the nurse gently lowers his arm. This phenomenon is termed a. echolalia. b. waxy flexibility. c. depersonalization. d. thought withdrawal.
ANS: B Waxy flexibility is the ability to hold distorted postures for extended periods of time, as though the client were molded in wax. Option A: Echolalia is a speech pattern. Option C: Depersonalization refers to a feeling state. Option D: Thought withdrawal refers to an alteration in thinking. DIF: Cognitive Level: Application REF: Text Page: 394 TOP: Nursing Process: Assessment MSC: NCLEX: Physiologic Integrity
What is a sensory perception that do not have an apparent stimuli?;
Hallucination
The nurse is told that a client with disorganized schizophrenia is being admitted to the unit. The nurse should expect the client to demonstrate a. highly suspicious, delusional behavior. b. extremes of motor activity and excitement to stupor. c. social withdrawal and ineffective communication. d. severe anxiety and ritualistic behavior.
ANS: C Clients with disorganized schizophrenia demonstrate the most regressed and socially impaired behaviors of the schizophrenias. Communication is often incoherent, with silly giggling and loose associations predominating. Option A relates more to paranoid schizophrenia. Option B relates to catatonic schizophrenia. Option D is seen with obsessive-compulsive disorder. DIF: Cognitive Level: Application REF: Text Page: 413 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
The physician is considering changing the antipsychotic medication for a client with schizophrenia who is troubled by the extrapyramidal symptoms of his current medication, haloperidol, and who seems to be becoming less motivated and more withdrawn. For planning purposes the nurse can assume that the physician will probably choose a. chlorpromazine (Thorazine). b. clozapine (Clozaril). c. olanzapine (Zyprexa). d. fluoxetine (Prozac).
ANS: C Olanzapine is an atypical antipsychotic that produces few extrapyramidal side effects and is effective in treating both positive and negative symptoms of schizophrenia. Option A: This drug often produces EPS. It is not effective in treating negative symptoms. Option B: Clozapine would not be the drug of choice because of the danger of agranulocytosis. Option D: Fluoxetine is a selective serotonin reuptake inhibitor antidepressant. DIF: Cognitive Level: Application REF: Text Page: 412 TOP: Nursing Process: Planning MSC: NCLEX: Physiologic Integrity
A salesman has had difficulty holding a job because he accuses co-workers of conspiring to take his sales. Today, he argued with several office mates and threatened to kill one of them. The police were called, and he was brought to the mental health center for evaluation. He has had previous admissions to the unit for stabilization of symptoms of paranoid schizophrenia. When the nurse meets him, he points at staff in the nursing station and states loudly "They're all plotting to destroy me. Isn't that true?" An appropriate response for the nurse would be a. "No, that is not true. People here are trying to help you if you will let them." b. "Everyone here is trying to help you. No one wants to harm you." c. "Thinking that people want to destroy you must be very frightening." d. "That is absurd. Staff are health care workers, not members of the mob."
ANS: C Resist focusing on content; instead, focus on the feelings the client is expressing. This strategy prevents arguing about the reality of delusional beliefs. Such arguments increase client anxiety and the tenacity with which the client holds to the delusion. The other options focus on content and provide opportunity for argument. DIF: Cognitive Level: Application REF: Text Page: 401 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
A client, newly diagnosed with paranoid schizophrenia, is delusional, withdrawn, and aloof. One of her nursing diagnoses is deficient diversional activity. An activity that would be appropriate to plan for the client early in the course of her hospital stay is a. a basketball game. b. ping-pong with another client. c. a paint-by-number project. d. a card game with three other clients.
ANS: C Solitary, noncompetitive activities that require concentration are best while the client is overtly psychotic. Having to concentrate minimizes hallucinatory and delusional preoccupation. Options A, B, and D are all competitive. DIF: Cognitive Level: Application REF: Text Page: 400 TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment;
A newly admitted client with schizophrenia approaches the unit nurse and says "The voices are bothering me. They are yelling and telling me I am bad. I have got to get away from them." The most helpful reply for the nurse to make would be a. "Do you hear the voices often?" b. "Do you have a plan for getting away from the voices?" c. "I'll stay with you. Focus on what we are talking about, not the voices. " d. "Forget the voices and ask some other clients to play cards with you."
ANS: C Staying with a distraught client who is hearing voices serves several purposes: ongoing observation, the opportunity to provide reality orientation, a means of helping dismiss the voices, the opportunity of forestalling an action that would result in self-injury, and general support to reduce anxiety. Option A is not particularly relevant at this point. Option B is relevant for assessment purposes but is less helpful than option C. Option D shifts responsibility for intervention from the nurse to the client and other clients. DIF: Cognitive Level: Application REF: Text Page: 401 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
A highly suspicious client who has delusions of persecution about being poisoned has refused all hospital meals for 3 days. Assuming all interventions listed are possible, the one likely to be most acceptable to the client is a. allowing the client to contact a local restaurant to deliver his meals. b. offering to taste each portion on the tray for the client. c. allowing the client supervised access to lobby food machines. d. providing tube feedings or total parenteral nutrition.
ANS: C The client who is delusional about his food being poisoned is likely to believe restaurant food might still be poisoned and to say that the staff member tasting the food has taken an antidote to the poison before tasting. Attempts to tube feed or give nutrition intravenously are seen as aggressive and usually promote violence. Clients perceive foods in sealed containers, packages, or natural shells as being safer. DIF: Cognitive Level: Application REF: Text Page: 414 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity
A client with schizophrenia tells the nurse "Everyone must listen to me. I am the redeemer. I will bring peace to the world." From this the nurse can determine that an appropriate nursing diagnosis to be completed is a. disturbed sensory perception: auditory. b. risk for other-directed violence. c. chronic low self-esteem. d. noncompliance: medication.
ANS: C The client's grandiose delusion is based on reaction formation to actual feelings of low self-esteem. The scenario does not provide sufficient data to support the other diagnoses. DIF: Cognitive Level: Analysis REF: Text Page: 391, Text Page: 392, Text Page: 396, Text Page: 397 TOP: Nursing Process: Nursing Diagnosis MSC: NCLEX: Psychosocial Integrity
A frightened, delusional client tells the nurse "I can't go to activities. When I am in a room with a lot of people I can feel them sucking my thoughts out of my head." The nurse can correctly assess this as a. anhedonia. b. concrete thinking. c. thought withdrawal. d. associative looseness.
ANS: C Thought withdrawal is defined as a delusional belief that someone or something is removing thoughts from the client's mind. Option A: Anhedonia is the inability to experience pleasure. Option B: Concrete thinking refers to the inability to use abstraction. Option D: Associative looseness refers to a lack of ties between thoughts, leading to jumbled thinking.
The physician and advanced practice nurse are considering which antipsychotic medication to prescribe for a client with schizophrenia who demonstrates auditory hallucinations, apathy, anhedonia, and poor social functioning. The client is overweight and has hypertension. Bearing these facts in mind, the drug the nurse should advocate would be a. clozapine (Clozaril). b. ziprasidone (Geodon). c. olanzapine (Zyprexa). d. aripiprazole (Abilify).
ANS: D Aripiprazole is a new atypical antipsychotic effective against both positive and negative symptoms of schizophrenia. It causes little or no weight gain and no increase in glucose, high- or low-density lipoprotein cholesterol, or triglycerides, making it a reasonable choice for a client with obesity or heart disease. Option A: Clozapine may produce agranulocytosis, making it a poor choice as a first-line agent. Option B: Ziprasidone may prolong the QT interval, making it a poor choice for a client with cardiac disease. Option C: Olanzapine fosters weight gain. DIF: Cognitive Level: Analysis REF: Text Page: 406 TOP: Nursing Process: Planning MSC: NCLEX: Physiologic Integrity
A client with schizophrenia anxiously describes seeing the left side of her body merge with the wall as she walked down the corridor and of seeing her face appear and disappear in the bathroom mirror. As the nurse listens she should a. sit close to the client on the bed. b. place an arm protectively around the client's shoulders. c. place a hand on the client's arm and exert light pressure. d. maintain the normal social interaction distance from the client.
ANS: D The client is describing phenomena that indicate personal boundary difficulties. The nurse should maintain appropriate social distance from the client and not touch her because the client is anxious about her inability to maintain ego boundaries and merging or being swallowed by the environment. Physical closeness or touch could precipitate panic. DIF: Cognitive Level: Application REF: Text Page: 393, Text Page: 394 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
A male client diagnosed with paranoid schizophrenia angrily tells the male nurse "You act like a homosexual. None of the men trust you or want to be around you." The nurse, who is heterosexual, is perplexed by the client's statements and discusses the event with his mentor. The most likely analysis of the event is a. the client was unleashing unconscious, hostile feelings toward the nurse. b. the client was demonstrating reaction formation in response to feelings of abandonment. c. dwelling on others' shortcomings puts them on the defensive. d. the client was projecting homosexual urges.
ANS: D Clients with paranoid ideation unconsciously use the defense mechanism projection to deal with unacceptable, anxiety-producing ideas and impulses, in this case homosexual urges. Option A: Although the behavior seems hostile, the projection is homosexual urges rather than hostility. Option B: Clients who exhibit paranoid ideation usually fear abandonment, but this situation does not represent reaction formation to abandonment feelings. Option C: Although this statement about defensive behavior is true, it is not the correct analysis of the behavior described in the scenario. DIF: Cognitive Level: Analysis REF: Text Page: 414 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
A client's nursing care plan includes assessment for auditory hallucinations. Indicators that suggest the client may be hallucinating include a. aloofness, haughtiness, and suspicion. b. elevated mood, hyperactivity, and distractibility. c. performing rituals and avoiding open places. d. darting eyes, tilted head, and mumbling to self.
ANS: D Clues to hallucinations include eyes looking around the room as though to find the speaker; tilting the head to one side as though listening intently; and grimacing, mumbling, or talking aloud as though responding conversationally to someone. DIF: Cognitive Level: Application REF: Text Page: 393 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
A client with schizophrenia who admits to auditory hallucinations anxiously tells the nurse "The voice is telling me to do things." The priority assessment question the nurse should ask is a. "Do you recognize the voice speaking to you?' b. "How long has the voice been directing your behavior?" c. "Does what the voice tell you to do frighten you?" d. "What is the voice telling you to do?"
ANS: D Learning what a command hallucination is telling the client to do is important because the command often places the client or others at risk for harm. Command hallucinations can be terrifying and may pose a psychiatric emergency. The other queries are of lesser importance than identifying the command. DIF: Cognitive Level: Application REF: Text Page: 393 TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment;
A client with the diagnosis of schizophrenia, disorganized type, approaches the nurse and says "It's beat, it's eat. No room. The cat." The nurse can correctly assess this verbalization as a. neologisms. b. ideas of reference. c. thought broadcasting. d. associative looseness.
ANS: D Looseness of association refers to jumbled thoughts that are often incoherently expressed to the listener. Option A: Neologisms are newly coined words. Option B: Ideas of reference are a type of delusion. Option C: Thought broadcasting is the belief that others can hear one's thoughts. DIF: Cognitive Level: Application REF: Text Page: 392, Text Page: 393 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
The nurse is sitting with a client diagnosed as having schizophrenia, disorganized type, who starts to laugh uncontrollably, although the nurse has not said anything funny. The nurse should say a. "Please share the joke with me." b. "Why are you laughing?" c. "I don't think I said anything funny." d. "You're laughing. Tell me what's happening."
ANS: D The client is likely laughing in response to inner stimuli such as hallucinations or fantasy. Moller suggests focusing on the hallucinatory clue (the client's laughter) and eliciting the client's observation. The other options are less useful in eliciting a response. Option A: No joke may be involved. Option B: "Why" questions are difficult to answer. Option C: The client is probably not focusing on what the nurse said in the first place. DIF: Cognitive Level: Application REF: Text Page: 393, Text Page: 401 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
When a client with paranoid schizophrenia has a recurrence of positive symptoms after stopping his antipsychotic medication to be free of its orthostatic side effect, he is readmitted to the mental health unit. The physician orders the resumption of medication. The nurse adds the nursing diagnosis of "noncompliance with antipsychotic medication regimen related to side effects" to the client's care plan. What measure should the nurse suggest to the client? a. Ask the physician about prescribing an anticholinergic drug such as trihexyphenidyl (Artane). b. Chew sugarless gum or use sugarless hard candy to moisten oral mucous membranes. c. Reduce dosage by 5 mg daily if side effects recur. d. Wear elastic support hose, stay hydrated, and rise slowly from the lying or sitting position.
ANS: D Orthostasis produces dizziness or fainting when moving from a lying or seated position to a standing position. This can be effectively combated by rising slowly. The use of support hose may also be helpful to prevent pooling of blood in the lower extremities. Options A and B are unnecessary. Anticholinergic side effects are not the problem. Option C The client should be taught not to discontinue or adjust the dose of the medication, but rather to report annoying side effects to the physician or nurse. DIF: Cognitive Level: Application REF: Text Page: 409 TOP: Nursing Process: Implementation MSC: NCLEX: Physiologic Integrity
The family of a client with schizophrenia who has been stable for a year reports to the community mental health nurse that the client reports feeling tense and having difficulty concentrating. He sleeps only 3 to 4 hours nightly and has begun to talk about "volmers" hiding in the warehouse where he works and undoing his work each night. The nurse can correctly assess this information as an indication of a. medication noncompliance. b. the need for psychoeducation. c. chronic deterioration. d. relapse.
ANS: D Signs of potential relapse include feeling tense, difficulty concentrating, trouble sleeping, increased withdrawal, and increased bizarre or magical thinking. Option A: Medication noncompliance may not be implicated. Relapse can occur even when the client is taking medication regularly. Option B: Psychoeducation is better delivered when the client's symptoms are stable. Option C: Chronic deterioration is not the most viable explanation. DIF: Cognitive Level: Application REF: Text Page: 399, Text Page: 400 TOP: Nursing Process: Assessment MSC: NCLEX: Physiologic Integrity
A client receiving risperidone (Risperdal) reports severe muscle stiffness mid-morning. During lunch he has difficulty swallowing food and is noted to drool. When vital signs are taken at 4 PM he is noted to be diaphoretic, with a temperature elevation of 38.4° C, pulse of 110 beats/min, and blood pressure of 150/90 mm Hg. The nurse should suspect a. agranulocytosis and institute reverse isolation. b. cholestatic jaundice and begin a high-protein, high-cholesterol diet. c. tardive dyskinesia and withhold the next dose of medication. d. neuroleptic malignant syndrome and notify physician stat.
ANS: D Taking an antipsychotic medication coupled with the presence of extrapyramidal symptoms such severe muscle stiffness and difficulty swallowing, hyperpyrexia, and autonomic symptoms (pulse elevation) suggest neuroleptic malignant syndrome, a medical emergency. The symptoms given in the scenario are not consistent with the medical problems listed in options A, B, or C. DIF: Cognitive Level: Analysis REF: Text Page: 409 TOP: Nursing Process: Assessment MSC: NCLEX: Physiologic Integrity
ANS: B Only option B relates to neurological findings. Options C and D refer to symptoms. Option A refers to family dynamics. DIF: Cognitive Level: Analysis REF: Text Page: 387 TOP: Nursing Process: Assessment MSC: NCLEX: Physiologic Integrity
ANS: D The atypical antipsychotic medications target both the negative and positive symptoms of schizophrenia, an obvious advantage over the standard antipsychotics; thus both sets of symptoms should be the foci of evaluation. No specific subset of disorganized symptoms is available. DIF: Cognitive Level: Analysis REF: Text Page: 405 TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity
A client with schizophrenia tells the nurse "I eat skiller. Tend to end. Easter. It blows away. Get it?" The best response for the nurse to make would be a. "Nothing you are saying is clear." b. "Your thoughts are very disconnected." c. "Try to organize your thoughts and then tell me again." d. "I am having difficulty understanding what you are saying."
ANS: D When a client's speech is loosely associated, confused, and disorganized, pretending to understand is useless. The nurse should tell the client that she is having difficulty understanding what the client is saying. If a theme is discernable, ask the client to talk about the theme. The other options tend to place blame for the poor communication with the client. Option D places the difficulty with the nurse rather than being accusatory. DIF: Cognitive Level: Application REF: Text Page: 401, Text Page: 402 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
The nurse attempting to establish a relationship with a severely withdrawn schizophrenic client tells a preceptor that her frustration level is rising daily because the client turns his head away each time she sits down near him. The nurse states "I am beginning to wonder what is wrong with me as a nurse." The preceptor could be most helpful by explaining that withdrawn clients with schizophrenia a. universally fear sexual involvement with therapists. b. are socially disabled by the positive symptoms of schizophrenia. c. exhibit a high degree of hostility by demonstrating rejecting behavior. d. avoid relationships because they become anxious with emotional closeness.
ANS: D When an individual is suspicious and distrustful and perceives the world and the people in it as potentially dangerous, withdrawal into an inner world can be a defense against uncomfortable levels of anxiety. When someone attempts to establish a relationship with such a client, the client's anxiety rises until trust is established. The truth of option A is not borne out by the evidence. Options B and C: These options are not considered true in most cases. DIF: Cognitive Level: Application REF: Text Page: 394, Text Page: 395 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment
What are the 4 A's associated with negative symptoms;
Affect- nonverbal expression of emotion. Person may have blunt or absence of nonverbal emotion called flat affect. No facial expressions are shown or other body language to indicate feelings. Alogia- decreased amount and richness of speech. Often called poverty of speech. A person with Alogia often has brief verbal responses, with little emotional expression. Avolition- lack of motivation. Patients with avolition often have difficulty initiating and persisting in goal directed behavior. As a result, these inidviduals often don't work. Anhedonia- is a lack of the ability to feel pleasure.
The most common hallucination is;
Auditory
First breaks for men are what age
Late teens to early twenties
What is a fixed, false belief?
Delusion
What neurotransmitters are affected with S?
Dopamine, Glutamate and Serotonin
What is echolalia?
Echolalia is the automatic repetition of vocalizations made by another person. It is closely related to echopraxia, the automatic repetition of movements made by another person.
What is an emergency/crisis related to s/s from antipsychotic meds?
NMS and anticholinergic crisis
What are two of the highest co-morbidities you see with Schizophrenia
Substance Abuse, Smoking
What is it called when one's thoughts have been removed from her body/mind;
Thought withdrawal
What are the common side effects of antipsychotic medications?;
Weight gain and orthostatic hypotension
First breaks for women are what age
mid twenties to late twenties
What is Schizoaffective d/o?
•Patient has schizophrenia, along with an affective disorder such as depression, mania or mixed
Schizophrenia affects thinking, emotions and.......;
•Thinking •Emotions •Behavior •Ability to perceive reality
