Assessment 3 N450- Scizophrenia

A client with bipolar disorder is reluctant to take lithium (Lithane) as prescribed. The MOST therapeutic response by the nurse to his refusal is? "You need to take your medicine, this is how you get well." "I can see that you are uncomfortable right now, I'll wait until tomorrow." "What is it about the medicine that you don't like?" "If you refuse your medicine, we'll just have to give you a shot."

"What is it about the medicine that you don't like?" Nursing interventions for clients with psychotic disorders are aimed at establishing a trusting relationship, establishing clear communications, presenting reality and reinforcing appropriate behavior.

A client on an in-patient psychiatric unit refuses to take medications because, "The pill has a special code written on it that will make it poisonous." What kind of delusion is this client experiencing? A grandiose delusion. A persecutory delusion. A somatic delusion. An erotomanic delusion.

*A persecutory delusion is a type of delusion in which the individual believes he or she is being malevolently treated in some way. Frequent themes include being conspired against, cheated, spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals. The situation described in the question reflects this type of delusion.*

1. A client diagnosed with schizophrenia is experiencing anhedonia. Which nursing diagnosis addresses concerns regarding this client's problem? Disturbed thought processes. Disturbed sensory perception. Risk for suicide. Impaired verbal communication.

*Risk for suicide is defined as a risk for self-inflicted, life-threatening injury. The negative symptom of anhedonia is defined as the inability to experience pleasure. This is a particularly distressing symptom that generates hopelessness and compels some clients to attempt suicide.* Disturbed thought processes is defined as the disruption in cognitive operations and activities. An example of a disturbed thought process is a delusion. The nursing diagnosis of disturbed thought processes does not address the symptom of anhedonia. Disturbed sensory perception is defined as a change in the amount or patterning of incoming stimuli (either internally or externally initiated), accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli. An example of a disturbed sensory perception is a hallucination. The nursing diagnosis of disturbed sensory perception does not address the symptom of anhedonia. Impaired verbal communication is defined as the decreased, delayed, or absent ability to receive, process, transmit, and use a system of symbols. The nursing diagnosis of impaired verbal communication does not address the symptom of anhedonia.

Which symptom experienced by a client diagnosed with schizophrenia would predict a less positive prognosis? Having little or no interest in work or social activities. Hearing hostile voices. Continuously repeating what has been said. Thinking the TV is controlling his or her behavior.

*When a client has little or no interest in work or social activities, the client is exhibiting the negative symptom of apathy. Apathy is indifference to, or disinterest in, the environment. Flat affect is a manifestation of emotional apathy. Because this client is exhibiting a negative symptom, the client has the potential for a poorer prognosis.* Hearing hostile voices, or auditory hallucinations, is a positive symptom of schizophrenia. Because this client is exhibiting a positive symptom, the client has the potential for a better prognosis. When the client thinks the TV is controlling his or her behavior, the client is experiencing the positive symptom of a delusion of control or influence. Because this client is exhibiting a positive symptom, the client has the potential for a better prognosis. When a client continuously repeats what has been said, the client is exhibiting the positive symptom of echolalia. Because this client is exhibiting a positive symptom, the client has the potential for a better prognosis.

General side effects of antipsychotics

-Extrapyramidal side effects (tremors, muscle spasms, rigidity, slow movements, restlessness) -Orthostatic hypotension -Tardive dyskinesia (lip smacking, tongue movement) -*Neuroleptic malignant syndrome- FATAL!*

4 As- Affect

-Flat -Blunt -Inappropriate -Bizarre Affects

Assessment: 4 As of schizophrenic client

1. Affect 2. Associative looseness 3. Autism 4. Ambivalence

Catatonic behavior

1. Stupor- decrease in reaction to the environment 2. Rigidity- Maintenance of a posture against efforts to be moved 3. Posturing (waxy flexibility) 4. Negativism- resistance to instructions 5. Excitement- Severely agitated; out of control 6. Potential for violence to self or others during stupor or excitement

Which statement is correct about a 25-year-old client with newly diagnosed schizophrenia? A Age of onset is typical for schizophrenia. B Age of onset is later than usual for schizophrenia. C Age of onset is earlier than usual for schizophrenia. D Age of onset follows no predictable pattern in schizophrenia

A Age of onset is typical for schizophrenia. The primary age of onset for schizophrenia is late adolescence through young adulthood (ages 17 to 27). Paranoid schizophrenia may sometimes have a later onset. All of the other options are incorrect.

A client tells the nurse that psychotropic medicines are dangerous and refuses to take them. Which intervention should the nurse use first? A Ask the client about any previous problems with psychotropic medications. B Ask the client if an injection is preferable. C Insist that the client take medication as prescribed. D Withhold the medication until client is less suspicious.

A Ask the client about any previous problems with psychotropic medications. The nurse needs to clarify the client's previous experience with psychotropic medication in order to understand the meaning of the client's statement. Asking the client if an injection is preferable may add to the client;s suspicion and feeling threatened. Withholding medication prescribed to relieve delusional beliefs will likely intensify paranoid thinking. Insisting that the client take medication can be a violation of his right to refuse treatment.

Ramsay is diagnosed with schizophrenia paranoid type and is admitted in the psychiatric unit of Nurseslabs Medical Center. Which of the following nursing interventions would be most appropriate? A Establishing a non demanding relationship B Encouraging involvement in group activities C Spending more time with Ramsay D Waiting until Ramsay initiates interaction

A Establishing a non demanding relationship A nonthreatening, non demanding relationship helps decrease the mistrust that is common in a client with paranoid schizophrenia. Encouraging involvement in group activities and spending more time with the client would be threatening for a client who is suspicious of other people's motives. This client is unlikely to initiate interaction; the nurse is responsible for initiating a relationship with the client.

Nurse Dorothy is evaluating care of a client with schizophrenia, the nurse should keep which point in mind? A Frequent reassessment is needed and is based on the client's response to treatment. B The family does not need to be included in the care because the client is an adult. C The client is too ill to learn about his illness. D Relapse is not an issue for a client with schizophrenia.

A Frequent reassessment is needed and is based on the client's response to treatment. Because client respond to treatment in different ways, the nurse must constantly evaluate the client and his potential. Premorbid adjustment must also be considered. Most clients with such condition go home, so the family should be involved. The client can learn about the illness if information is provided gradually. Relapse is common in schizophrenia.

Grandiose delusion

A grandiose delusion is a type of delusion in which the individual has an irrational idea regarding self-worth, talent, knowledge, or power.

Word salad

A mixture of words and phrases that lack comprehensive meaning or logical coherence; commonly seen in schizophrenic states. "Go great the fate bowl"

Somatic delusion

A somatic delusion is a type of delusion in which individuals believe they have some sort of physical defect, disorder, or disease.

A schizophrenic client who is taking fluphenazine decanoate is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse about a planned vacation and will return in 18 days. Which statement by the client indicates to the nurse a need for health teaching? A. "I am going to have lots of fun at the beach and plenty of time in the sun." B. "While I am on vacation, I will not eat or drink anything that contains alcohol." C. "I will notify the health care provider if I have a sore throat or flulike symptoms." D. "I will continue to take my benztropine mesylate every day."

A. "I am going to have lots of fun at the beach and plenty of time in the sun." Rationale: Photosensitivity is a side effect of fluphenazine decanoate, so the client should be instructed to avoid the sun. Options B, C, and D indicate accurate knowledge. Alcohol acts synergistically with fluphenazine decanoate. A sore throat and flulike symptoms are signs of agranulocytosis, which is also a side effect of Prolixin. To avoid extrapyramidal symptoms (EPS), anticholinergic drugs, such as Cogentin, are often prescribed prophylactically with fluphenazine decanoate.

A 38-year-old client is admitted with a diagnosis of paranoid schizophrenia. When the lunch tray is brought to the room, the client refuses to eat and tells the nurse, "I know you are trying to poison me with that food." Which response by the nurse is the most therapeutic? A. "I'll leave your tray here. I am available if you need anything else." B. "You're not being poisoned. Why do you think someone is trying to poison you?" C. "No one on this unit has ever died from poisoning. You're safe here." D. "I will talk to your health care provider about the possibility of changing your diet."

A. "I'll leave your tray here. I am available if you need anything else." Rationale: Option A is the best choice because the nurse does not argue with the client or demand that the client eat but offers support by agreeing to be there if needed, which provides an open, rather than closed, response to the client's statement. Options B and C are challenging the client's delusions, and option B asks "why." Probing questions, which start with "why," are usually not therapeutic communication for a psychotic client. Option D has not addressed the actual problem—that is, the client's delusions.

A client who has been hospitalized for 2 weeks for paranoia reports continuously to the staff that someone is trying to steal his clothing. What is the correct action for the nurse to take based on the client's complaints? A. Enroll the client in an exercise class to promote positive activities. B. Place a lock on the client's closet to allay the client's concerns. C. Promote extinction of the ideation by ignoring the client. D. Explain to the client that these suspicions are certainly false.

A. Enroll the client in an exercise class to promote positive activities. Rationale: Diverting the client's attention from paranoid ideation and encouraging the client to engage in positive activities can be helpful in assisting to develop a positive self-image. Option B actually supports paranoid ideation. Option C may lower self-esteem. The nurse should not argue with the client about the delusions (option D).

The nurse develops a plan of care for a client with symptoms of paranoia and psychosis. The priority nursing diagnosis is impaired social interactions related to inability to trust. Which intervention is most important for the nurse to implement? A. Greet the client by first name during each social interaction. B. Determine if the client is experiencing auditory hallucinations. C. Introduce the client to peers on the unit as soon as possible. D. Assign the client to a group about developing social skills.

A. Greet the client by first name during each social interaction. Rationale: The most important nursing intervention is to greet the client by name and provide short frequent contact to establish trust. The presence of auditory hallucinations can affect social interactions, but option B is not a priority intervention. Options C and D are effective interventions after individual rapport has been established with the client.

Which topics should the nurse include in an education program for clients with schizophrenia and their families? (Select all that apply.) A. Importance of adherence to medication regimen B. Current treatment measures for substance abuse C. Signs and symptoms of an exacerbation D. Prevention of criminal activity E. Behavior modification for aggression F. Chronic grief associated with long-term illness

A. Importance of adherence to medication regimen C. Signs and symptoms of an exacerbation F. Chronic grief associated with long-term illness Rationale: Medication adherence is an important component of successful rehabilitation (A). Clients and their families also need to know the signs and symptoms of an exacerbation or relapse of the disease (C), which is frequently associated with poor medication compliance. Acknowledging the chronic sorrow associated with severe and persistent mental illness (F) helps individuals negotiate the grieving process. (B, D, and E) are not universal problems associated with schizophrenia.

A client begins taking an atypical antipsychotic medication. The nurse must provide informed consent and education about common medication side effects. Which client education will be most important? A. Maintain a balanced diet and adequate exercise. B. Be sure that the diet is adequate in salt intake. C. Monitor for any changes in sleep pattern. D. Report any unusual facial movements.

A. Maintain a balanced diet and adequate exercise. Rationale: Several atypical antipsychotic medications can cause significant weight gain, so the client should be advised to maintain a balanced diet and adequate exercise. Option B is important with lithium, a mood stabilizer. Options C and D are less common than weight gain.

After taking chlorpromazine (Thorazine) for 1 month, a client presents to an emergency department (ED) with severe muscle rigidity, tachycardia, and a temperature of 105oF (40.5C). The nurse expects the physician to recognize which condition and implement which treatment? A. Neuroleptic malignant syndrome and treat by discontinuing Thorazine and administering dantrolene (Dantrium) B. Neuroleptic malignant syndrome and treat by increasing Thorazine dosage and administering an antianxiety medication C. Dystonia and treat by administering trihexyphenidyl (Artane) D. Dystonia and treat by administering bromocriptine (Parlodel)

ANS: AThe nurse should expect that an ED physician would diagnose the client with neuroleptic malignant syndrome and treat the client by discontinuing chlorpromazine (Thorazine) and administering dantrolene (Dantrium). Neuroleptic malignant syndrome is a potentially fatal condition characterized by muscle rigidity, fever, altered consciousness, and autonomic instability. The use of typical antipsychotics is largely being replaced by atypical antipsychotics due to fewer side effects and lower risks.

A client diagnosed with schizophrenia is slow to respond and appears to be listening to unseen others. Which medication should a nurse expect a physician to order to address this type of symptom? A. Haloperidol (Haldol) to address the negative symptom B. Clonazepam (Klonopin) to address the positive symptom C. Risperidone (Risperdal) to address the positive symptom D. Clozapine (Clozaril) to address the negative symptom

ANS: C The nurse should expect the physician to order risperidone (Risperdal) to address the positive symptoms of schizophrenia. Risperidone (Risperdal) is an atypical antipsychotic used to reduce positive symptoms, including disturbances in content of thought (delusions), form of thought (neologisms), or sensory perception (hallucinations).

A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol) 50 mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg HS. Which client behavior would warrant the nurse to administer benztropine? A. Tactile hallucinations B. Tardive dyskinesia C. Restlessness and muscle rigidity D. Reports of hearing disturbing voices

ANS: C The symptom of tactile hallucinations and reports of hearing disturbing voices would be addressed by an antipsychotic medication such as haloperidol. Tardive dyskinesia, a potentially irreversible condition, would warrant the discontinuation of an antipsychotic medication such as haloperidol. An anticholinergic medication such as benztropine would be used to treat the extrapyramidal symptoms of restlessness and muscle rigidity.

A client diagnosed with chronic schizophrenia presents in an emergency department (ED) with uncontrollable tongue movements, stiff neck, and difficulty swallowing. The nurse would expect the physician to recognize which condition and implement which treatment? A. Neuroleptic malignant syndrome and treat by discontinuing antipsychotic medications B. Agranulocytosis and treat by administration of clozapine (Clozaril) C. Extrapyramidal symptoms and treat by administration of benztropine (Cogentin) D. Tardive dyskinesia and treat by discontinuing antipsychotic medications

ANS: D The nurse should expect that an ED physician would diagnose the client with tardive dyskinesia and discontinue antipsychotic medications. Tardive dyskinesia is a condition of abnormal involuntary movements of the mouth, tongue, trunk, and extremities that can be an irreversible side effect of typical antipsychotic medications.

A client with schizophrenia has been started on medication therapy with clozapine (Clozaril). A nurse assesses the results of which laboratory study to monitor for adverse effect related to this medication? A White blood cell. B Platelet count. C Liver function studies. D Random blood sugar

Agranulocytosis my experience by the client taking clozapine which can be monitored by evaluating the white blood cell count. Options B, C, and D are not related specifically to the use of the medication.

Erotomanic delusion

An erotomanic delusion is a type of delusion in which the individual believes that someone, usually of higher status, is in love with him or her.

Nurse Winona educates the family about symptom management for when the schizophrenic client becomes upset or anxious. Which of the following would Nurse Winona state is helpful? A Call the therapist to request a medication change. B Encourage the use of learned relaxation techniques. C Request that the client be hospitalized until the crisis is over. D Wait before the anxiety worsens before intervening.

B Encourage the use of learned relaxation techniques. The client with schizophrenia can learn relaxation techniques, which help reduce anxiety. The family can be supportive and helpful by encouraging the client to use these techniques. Anxiety is a common experience for everyone, and is no reason to change medication. Handling anxiety is a learned skill that is important to reinforce. There is no indication that the client is in crisis. It is much easier to intervene early in anxiety rather than waiting until escalation occurs.

Cersei is diagnosed as having disorganized schizophrenia. Which behaviors would Nurse Sansa most likely assess in the client? A Absence of acute symptoms, impaired role function B Extreme social withdrawal, odd mannerisms and behavior C Psychomotor immobility; presence of waxy flexibility D Suspiciousness toward others, increased hostility

B Extreme social withdrawal, odd mannerisms and behavior Disorganized schizophrenia is characterized by regressive behavior with extreme social withdrawal and frequently odd mannerisms. The absence of acute symptoms and impaired role function are more characteristic of residual-type schizophrenia. Psychomotor immobility and presence of waxy flexibility are more indicative of catatonic schizophrenia. Suspiciousness toward others and increased hostility is more characteristic of paranoid schizophrenia.

Which of the following client behaviors documented in Gio's chart would validate the nursing diagnosis of Risk for other-directed violence? A Gio's description of being endowed with superpowers B Frequent angry outburst noted toward peers and staff C Refusal to eat cafeteria food D Refusal to join in group activities

B Frequent angry outburst noted toward peers and staff Anger is an important factor that indicated the potential for acting out. Because the client is angry with both peers and staff, any acting out would probably be directed toward others. The client's description of being endowed with superpowers and his refusal to eat cafeteria food indicate that he may have delusional beliefs, but not necessarily a risk for violence. Refusal to join in group activities indicates discomfort with a group, however, no threat of violence is apparent.

Nurse Arya assesses for evidence of positive symptoms of schizophrenia in a newly admitted client. Which of the following symptoms are considered positive evidence? Select all that apply. A. Anhedonia B. Delusions C. Flat affect D. Hallucinations E. Loose associations F. Social withdrawal

B,D,E Delusions, Hallucinations, Loose associations

A 25-year-old client has suffered extensive burns and is crying during dressing change treatment. The client tells the nurse, "Please let me die. Why are you all torturing me like this? I just want to die." Which response by the nurse is best? A. "We aren't torturing you. These treatments are necessary to prevent a terrible infection." B. "I know these treatments must seem like torture to you, but we want to help you recover." C. "You have so much to live for, and all of your family members want you to live." D. "Would you like me to call the chaplain so that you can discuss your feelings privately?"

B. "I know these treatments must seem like torture to you, but we want to help you recover." Rationale: Options B offers an empathetic response without sounding patronizing. Options A is not empathetic and is actually somewhat argumentative. The client is not asking for information as much as pleading for understanding. Option C appears as scolding and places blame on the client for wanting to die and possibly hurting the client's family members as a result. Option D might be appropriate if the nurse simply asks the client if a chaplain's visit is desired, but the nurse is dismissing the client's needs by not addressing them at the moment.

A client in an acute care facility has been taking antipsychotic medications for the past 3 days with a decrease in psychotic behaviors and no adverse reactions. On the fourth day, the client experiences an increase in blood pressure and temperature and demonstrates muscular rigidity. Which action should the nurse initiate? A. Place the client on seizure precautions and monitor frequently. B. Take the client's vital signs and notify the health care provider immediately. C. Describe the symptoms to the charge nurse and document them in the client's record. D. No action is required at this time because these are known side effects of the medications.

B. Take the client's vital signs and notify the health care provider immediately. Rationale: This is an emergency situation, and the client requires immediate management in a critical care setting. These symptoms are descriptive of neuroleptic malignant syndrome (NMS), an extremely serious and life-threatening reaction to neuroleptic drugs. The major symptoms of this syndrome are fever, rigidity, autonomic instability, and encephalopathy. Respiratory failure, cardiovascular collapse, arrhythmias, and/or renal failure can result in death. Option A is not indicated in this situation. Option C does not consider the seriousness of the situation. Option D is an incorrect statement.

The primary goal in working with an actively psychotic, suspicious client would be to a. promote interaction with others b. decrease his anxiety and increase trust c. improve his relationship with his parents d. encourage participation in therapy activities

B. decrease his anxiety and increase trust

Tony, age 21, has been diagnosed with Schizophrenia. He has been socially isolated and hearing voices telling him to kill his parents. He has been admitted to the psychiatric unit from the emergency department. The INITIAL nursing intervention for Tony is to a. give him an injection of Thorazine b. ensure a safe environment for him and others c. place him in restraints d. order him a nutritious diet

B. ensure a safe environment for him and others

During a home visit, a client with schizophrenia reports hearing voices that tell the client to walk in the middle of the street. The nurse records several statements made by the client. Based on which statement should the nurse determine that the client needs hospitalization? A. "Sometimes I take an extra one of my pills when I hear the voices." B. "The voices are louder when I forget to take my medication." C. "No matter what I do, I cannot make the voices go away." D. "I just try to tell the voices to stop when they bother me."

C. "No matter what I do, I cannot make the voices go away." Rationale: Hospitalization is needed if the client continues to hear voices telling the client to do things that can cause self-harm. Option A or B does not require hospitalization unless symptoms become severe. The client should continue symptom management strategies to prevent hospitalization.

A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows that he is not. Which response is best for the nurse to make? A. "Did you really believe you were Jesus Christ?" B. "I think you're getting well." C. "Others have had similar thoughts when under stress." D. "Why did you think you were Jesus Christ?"

C. "Others have had similar thoughts when under stress." Rationale: Option C offers support by assuring the client that others have experienced similar situations. Option A is belittling. Option B is making an inappropriate judgment. You may have narrowed your choices to options C and D. However, you should eliminate option D because it is a "why" question, and the client does not know why.

A client in the critical care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveals no significant changes, and the nurse formulates the diagnosis of confusion related to ICU psychosis. Which intervention is best to implement based on this client's behavior? A. Move all medical equipment away from the client's bedside. B. Allay fears by teaching the client about the causes of the disease. C. Cluster care to allow for brief rest periods during the day. D. Encourage visitation by the client's family members, including the client's young children.

C. Cluster care to allow for brief rest periods during the day. Rationale: The best intervention is to organize care so that the client can experience rest periods. The critical care unit contains many lifesaving treatment modalities that offer clients an array of auditory, visual, and even painful stimuli. These stressors can result in isolation and confusion. Option A is not practical because the client may need assistance from medical equipment to survive. The client is too ill to receive teaching (Option B). Although option D may be supportive, young children are routinely prohibited from critical care units because of increased risk of infectious disease transmission.

REVIEW MODE: PsychiatricQuestion 27 of 50ID: 8_31 Home Calculator Help Back Next A 35-year-old client admitted to the psychiatric unit of an acute care hospital tells the nurse that someone is trying to poison her. The client's delusions are most likely related to which factor? A. Authority issues in childhood B. Anger about being hospitalized C. Low self-esteem D. Phobia of food

C. Low self-esteem Rationale: Delusional clients have difficulty with trust and have low self-esteem. Nursing care should be directed at building trust and promoting positive self-esteem. Activities with limited concentration and no competition should be encouraged to build self-esteem. Options A, B, and D are not specifically related to the development of delusions.

The nurse is caring for a client with schizophrenia. Orders from they physician include 100 mg chlorpromazine IM STAT and then 50 mg PO BID; 2 mg benztropine PO BID PRN. Why is chlorpromazine ordered? a. to reduce extrapyramidal symptoms b. to prevent neuroleptic malignant syndrome c. to decrease psychotic symptoms d. to induce sleep

C. to decrease psychotic symptoms

Schizophrenia is diagnosed when

Client experiences 2+ symptoms during a 1 month period and at least 1 symptom must be a core positive symptom (delusions, hallucinations, disorganized speech)

The nurse asks the client, "what brought you to the hospital?" The client's response is, "The bus." What type of thinking is the client exhibiting?

Concrete thinking

4 As- Associative looseness

Confused thinking with illogical speech and reasoning

Nurse should reinforce _________ thinking...

Congruent thinking and stress reality!!

The family of a schizophrenic client asks the nurse if there is a genetic cause of this disorder. To answer the family, which fact would the nurse cite? A Conclusive evidence indicates a specific gene transmits the disorder. B Incidence of this disorder is variable in all families. C There is a little evidence that genes play a role in transmission. D Genetic factors can increase the vulnerability for this disorder.

D Genetic factors can increase the vulnerability for this disorder. Research shows that family history statistically increases the risk for development of schizophrenia. However, no single gene has yet been identified. Options B and and C are both incorrect because genetics plays a role in the etiology of schizophrenia.

Which factor is associated with increased risk for schizophrenia? A Alcoholism B Adolescent pregnancy C Overcrowded schools D Poverty

D Poverty Low socioeconomic status or poverty is an identified environmental factor associated with increased incidence of schizophrenia. Although alcoholism, adolescent pregnancy, and overcrowded schools may be stressful, research does not show they increase the risk of schizophrenia.

Upon Sam's admission for acute psychiatric hospitalization, Nurse Jona documents the following: Client refuses to bathe or dress, remains in room most of the day, speaks infrequently to peers or staff. Which nursing diagnosis would be the priority at this time? A Anxiety B Decisional conflict C Self-care deficit D Social isolation

D Social isolation These behaviors indicate the client's withdrawal from others and possible fear or mistrust of relationships. There is no indication of Anxiety or Decisional conflict in the information provided. Although the client refuses to bathe or dress, Self-care deficit would not be the priority nursing diagnosis in this situation.

Jaime has a diagnosis of schizophrenia with negative symptoms. In planning care for the client, Nurse Brienne would anticipate a problem with: A auditory hallucinations. B bizarre behaviors. C ideas of reference. D motivation for activities

D motivation for activities In a client demonstrating negative symptoms of schizophrenia, avolition, or the lack of motivation for activities, is a common problem. All of the other symptoms listed are the positive symptoms of schizophrenia.

A 25-year-old client has been particularly restless, and the nurse finds the client trying to leave the psychiatric unit. The client tells the nurse, "Please let me go! I must leave because the secret police are after me." Which response is best for the nurse to make? A. "No one is after you. You're safe here." B. "You'll feel better after you have rested." C. "I know you must feel lonely and frightened." D. "Come with me to your room, and I will sit with you."

D. "Come with me to your room, and I will sit with you." Rationale: Option D is the best response because it offers support without judgment or demands. Option A is challenging the client's delusion. Option B is offering false reassurance. Option C is a violation of therapeutic communication because the nurse is telling the client how she or he feels (frightened and lonely), rather than allowing the client to describe his or her own feelings. Hallucinating and delusional clients are not capable of discussing their feelings, particularly when they perceive a crisis.

A client mumbles out loud whether anyone is talking to her or not, and the client also mumbles in group when others are talking. The nurse determines that the client is experiencing hallucinations. Which intervention should the nurse implement? A. Respond to the client's feelings rather than the illogical thoughts. B. Identify beliefs and thoughts about what the client is experiencing. C. Provide the client with hope that the voices will eventually go away. D. Ask the client how she has previously managed the voices.

D. Ask the client how she has previously managed the voices. Rationale: The nurse should promote symptom management and determine how the client previously managed the voices. Options A and B are interventions that are useful with clients who are experiencing delusions. Option C is important, but the most important intervention is to promote symptom management.

Which behavior indicates to the nurse that a client with paranoid ideas is improving? A. Arrives on time for all activities B. Talks more openly about plans to protect his possessions C. Aggressively uses the punching bag in the gym D. Discusses his feelings of anxiety with the nurse

D. Discusses his feelings of anxiety with the nurse Rationale: Anxious feelings increase paranoid ideation. If the client is able to discuss these feelings, then the client is improving because of fewer paranoid ideas. Option A would indicate that a client with depression or one who is passive-aggressive is improving. Option B indicates feelings of paranoia. Option C indicates the release of anger, and "anger turned inward" is sometimes used as a definition for depression.

HESI HINT one how nurse should act when client is experiencing delusions

DO NOT ARGUE WITH A CLIENT ABOUT THEIR DELUSIONS. Logic does not work; it only increases the client's anxiety. Be matter of fact and divert delusional thought into reality. Trust is the basis for all interaction with any clients. Be supportive, nonjudgmental. Stress increases anxiety and the need for delusions and hallucinations. *Do not agree that you hear voices but do acknowledge your observation of the client; for example: "You look like you're listening to something", or "I understand that you are hearing voices but I can not hear those voices". *

A client has been sitting in the same position for 2 hours. He is mute. What type of illness is the client experiencing?

Delusion of grandeur; approach client and offer solitary activity as distraction. Assess need for medication. Encourage verbalization of feeling and promote outlet for expression. The delusion is paranoid disorder with delusions of reference.

Antipsychotics- Extrapyramidal side effects

EXTRAPYRAMIDAL effects are caused by the antipsychotics that are responsible for controlling the positive symptoms of schizophrenia in which they block dopamine receptors- decrease dopamine re uptake. *Parkinsonism behaviors* -occur within 1-4 weeks after initiation of tx -Rigidity, tremors *Akathisia* -occur within 1-6 weeks after initiation of tx -Restlessness, agitation, acing, sudden difficulty sitting still *Dystonia* -occurs within 1-2 days after tx -Limb and neck spasms, jerky movements, rigidity *Tardive dyskinesia develops late in tx* -(lip smacking, tongue movements, pill rolling), shuffling gait, mask like face? 1) Teach pt. to report side effects early 2) Administer anticholinergic drugs such as benadryl, ativan, vitamin E, Symmetrel, Congentin, Artane which acts on the extrapyramidal system to reduce disturbing symptoms

Antipsychotics- Neuroleptic malignant side effects

FATAL!!! Risk increased when taking phenothiazines (typical antipsychotics) and caused when they block the dopamine receptors. *Fever of 103-105+ degrees* *BP lability* *Tachycardia >130* *Tachypnea >25 RR* *Diaphoresis* *Pallor* *Muscle rigidity (arm/abdomen board like)* *Increased WBC* *Renal failure* The use of typical antipsychotics is largely being replaced by atypical antipsychotics due to fewer side effects and lower risks. -Stop antipsychotic immediately -Hospitalization needed -Lab test needed (CK) to determine muscle injury -Treat symptoms- hydration, ventilation, enal dialysis, reduce fever -Administer NMS meds (dantrolene- muscle relaxant), (Levodpa- to increase dopamine levels), lorazepam- sedative)

Regression in schizophrenic client

Falling back to earlier behavioral levels: fetal position, eating with hands etc.

4 As- Ambivalence

Holds opposing emotions, attitudes, ideas at the same time, difficulty, making decisions

What interventions are focused on with schizophrenic clients?

Interventions that decrease stress; since stress exacerbates symptoms

Neologisms

Made-up words that typically have only meaning to the individual who uses them.

Schizophrenia is

Marked by profound withdrawal from interpersonal relationships and cognitive/perceptual disturbances that make dealing with reality difficult Cause: Excess of dopamine dependent neuronal activity in the brain. Antipsychotics (Chlorpromazine or haloperidol) lower brain levels of dopamine by blocking dopamine receptors thus reducing schizophrenic symptoms.

When evaluating client behaviors, consider the ________ the client is receiving

Medications! Exhibited behaviors may be manisfestations of schizophrenia or a drug reaction

4 As- Autism

Not in reality; delusions, hallucinations, neologisms, preoccupied with self

Positive symptoms (hallucination, delusions, speech impairment)

Positive symptoms tend to reflect an alteration or distortion of normal mental fx. Psychotic NEW symptoms! -Normal scans and testing -Respond well to meds Delusions -Control -Reference Hallucinations -Sensations that are not there (voices) Disorganized speech -Word salad = mixture of meaningless phrases "go great the fate bowl" -Clanging- use of rhyming words "be glad, you're sad, i'm bad" Disorganized/ Catatonic behavior -Not moving, stupor

A client is sitting alone talking quietly. There is no one around. What nursing action should be taken?

Quietly approach the client and note the behavior. Assess the content of the hallucinations ("I notice you talking. Are you hearing voices? Can you tell me about those voices you are hearing?") The nurse should spend time with the client, assess with ADLs; be alert to potential for violence toward self or others; be aware of fluid and nutrition needs. *DO NOT REINFORCE THE HALLUCINATIONS, USE THE "VOICES" INSTEAD OF WORDS LIKE "THYE" THAT IMPLY VALIDATION. LET CLIENT KNOW THAT YOU DO NOT SHARE THE PERCEPTION. SAY, "EVEN THOUGH I REALIZE THE VOICES ARE REAL TO YOU, I DO NOT HEAR ANY VOICES".

Negative symptoms (apathy, poverty of thought, anhedonia, impaired decision making)

Removal of normal processes- decrease in emotions or loss of interest *FLAT AFFECT* where they don't respond to emotion that would seem appropriate Alogia- lack of speech Example: Nurse asks, do you have any children? Client will just say "Yes." Anhedonia- inability to feel pleasure Apathy- lack of interest Thought blocking- stops talking in the middle of sentence and remains silent Avolitition- lack of motivation Anergia- lack of energy -Abnormal scans and testing -More difficult to treat than positive but atypical anti psychotics (new gen meds) show better response

Antipsychotics- Agranulocytosis side effects

Significant risk with Clozapine. Agranulocytosis is a potential fatal blood disorder in which the client's white blood cells count can drop to extremely low levels (<4,000) thus symptoms of sore throat, fever, malaise should be monitored.

A nurse notes that a client with schizophrenia and receiving an antipsychotic medication is having uncontrolled movement of the lips and tongue. The nurse determines that the client is experiencing? A Hypertensive crisis. B Parkinsonism. C Tardive dyskinesia. D Neuroleptic malignant syndrome.

Tardive dyskinesia is characterized by uncontrollable involuntary movements of the body and extremities (especially of the face, lips, mouth, tongue, arms or legs). Option A: Hypertensive crisis occurs from the use of MAOIs. Option B: Parkinsonism is characterize by tremor, slow movement, impaired speech or muscle stiffness. Option D: Neuroleptic malignant syndrome is a life-threatening condition caused by an adverse reaction to antipsychotic drugs. Symptoms include high fever, sweating, unstable blood pressure, stupor, muscular rigidity, and autonomic dysfunction.

Echoliaia

The client repeats words that he or she hears in attempt to identify with the person speaking. Ex. The nurse says, "John, it's time for lunch". The client will respond with, "It's time for lunch, it's time for lunch, lunch lunch lunch".

Which of the following classifications of medications would be MOST often used for clients with schizophrenia? Anti-depressants Mood stabilizers Anxiolytics Neuroleptics

The correct option is Neuroleptics. Neuroleptics are antipsychotic drugs which are most beneficial in treating the signs and symptoms of schizophrenia; any of the other medications might also be used, but neuroleptics are the most widely used.

loose associations (derailment)

The individual is unaware that the topics are unconnected and speech my be incoherent if severe. "We wanted to take the bus, but the airport took all the traffic. Driving is the ticket when you want to get somewhere. No one needs a ticket to heaven. We have it all in our pockets".

concrete thinking

Thinking grounded in immediate experience rather than abstraction. There is an overemphasis on specific detail as opposed to general and abstract concepts. "The cop brought me into the hospital", when in abstract thinking, his condition brought him into the hospital. The client will not be able to understand phrases such as "It's raining cats and dog".

Clanging

Use of meaningless, rhyming words "Be glad, you're sad, i'm bad"

Clint, a client on the psychiatric unit, has been diagnosed with Schizophrenia. He begins to tell the nurse about how the CIA is looking for him and will kill him if they find him. Clint's belief is an example of a a. delusion of persecution b. delusion of reference c. delusion of control or influence d. delusion of grandeur

a. delusion of persecution

The nurse is interviewing a client on he psychiatric unit. The client tilts his head to the side, stops talking mid-sentence, and listens intently. The nurse recognizes these behaviors as a symptom of the client's illness. The most appropriate nursing intervention for this symptom is to: a. ask the client to describe his physical symptoms b. ask the client to describe what he is hearing c. administer a dose of benztropine d. call the physician for additional orders

b. ask the client to describe what he is hearing

Gio told his nurse that the FBI is monitoring and recording his every movement and that microphones have been plated in the unit walls. Which action would be the most therapeutic response? a. Confront the delusional material directly by telling Gio that this simply is not so. b.Tell Gio that this must seem frightening to him but that you believe he is safe here. c.Tell Gio to wait and talk about these beliefs in his one-on-one counselling sessions. d. Isolate Gio when he begins to talk about these beliefs.

b.Tell Gio that this must seem frightening to him but that you believe he is safe here. he nurse must realize that these perceptions are very real to the client. Acknowledging the client's feelings provides support; explaining how the nurse sees the situation in a different way provides reality orientation. Confronting the delusional material directly will not work with this client and may diminish trust. Telling the client to wait and talk about these beliefs in his one-on-one counselling session will reinforce the delusion. Isolation will increase anxiety. Distraction with a radio or activities would be a better approach.

The nurse is interviewing a client on the psychiatric unit. The client tilts his head to the side, stops talking in mid-sentence, and listens intently. The nurse recognizes from these signs that the client is likely experiencing a. somatic delusions b. catatonic stupor c. auditory hallucinations d. pseudoparkinsonism

c. auditory hallucinations

When a client suddenly becomes aggressive and violent on the unit, which of the following approaches would be best for the nurse to use FIRST? a. provide large motor activities to relieve the client's pent-up tension. b. Administer a dose of prn chlorpromazine to keep the client calm c. call for sufficient help to control the situation safely d. convey to the client that his behavior is unacceptable and will not be permitted

c. call for sufficient help to control the situation safely

Clint, a client on the psychiatric unit, has been diagnosed with Schizophrenia. He begins to tell the nurse about how the CIA is looking for him and will kill him if they find him. The most appropriate response by the nurse is: a. "thats ridiculous, Clint. No one is going to hurt you." b. " The CIA isnt interested in people like you, Clint." c. "why do you think the CIA wants to kill you?" d. "I know you believe that, Clint, but it's really hard for me to believe."

d. "I know you believe that, Clint, but it's really hard for me to believe."

The nurse s caring for a client with schizophrenia. Orders from the physician include 100 mg chlorpromazine IM STAT and then 50 mg PO BID; 2 mg benztropine PO BID PRN. Because benztropine was ordered on a PRN basis, which of the following assessments by the nurse would convey a need for this medication? a. the client's level of agitation increases b. the client complains of a sore throat c. the clients skin has a yellowish cast d. the client develops tremors and a shuffling gait

d. the client develops tremors and a shuffling gait

The primary focus of family therapy for clients with schizophrenia and their families is a. to discuss concrete problem solving and adaptive behaviors for coping with stress b. to introduce the family to others with the same problem c. to keep the client and family in touch with the health care system d. to promote family interaction and increase understanding of the illness

d. to promote family interaction and increase understanding of the illness

Drogo who has had auditory hallucinations for many years tells Nurse Khally that the voices prevents his participation in a social skills training program at the community health center. Which intervention is most appropriate? a.Let Drogo analyze the content of the voices. b.Advise Drogo to participate in the program when the voices cease. c.Advise Drogo to take his medications as prescribed. d.Teach Drogo to use thought stopping techniques.

d.Teach Drogo to use thought stopping techniques. Clients with long-lasting auditory hallucinations can learn to use thought stopping measures to accomplish tasks. Analyzing the content of the voices may be indicated when hallucinations first occur to establish whether the voices are threatening to the client or instructing him to harm others. However, focusing on their content at this point would reinforce this symptom. The voices have lasted many years; the client should participate despite the voices. There is no indication that the client is not taking medication as prescribed.

depersonalization/derealization disorder

individuals feel detached from their own mind and body (depersonalization) or from their surroundings (derealization) "I slept in the dungeon last night and it was so cold"