Cognition
A 56-year-old man is admitted to the inpatient unit after family members report that he seems to be experiencing auditory hallucinations. The man has a history of schizophrenia and has had several previous admissions. Which statement indicates to the nurse that the client is experiencing auditory hallucinations? "Get these horrible snakes out of my room!" "I am not the devil! Stop calling me those names!" "The food on this plate has poison in it, so take it away—I won't eat it." "I did see an alien spaceship last night outside in my yard, and I've felt worse ever since."
"I am not the devil! Stop calling me those names!" The client is responding to messages that he is hearing, which are auditory hallucinations. The responses regarding the snakes and the spaceship are examples of visual hallucinations because they describe what the client sees. The accusation of poisoning is the statement of a client who is suspicious and paranoid but not hallucinating.
A client with schizophrenia is demonstrating waxy flexibility. Which intervention is the best way to manage the possible outcome of this behavior? Providing thickened liquids to minimize the risk of aspiration Documenting intake and output each shift to monitor hydration Reinforcing appropriate social boundaries through staff role modeling Passive range-of-motion exercises three times a day for effective joint health
Passive range-of-motion exercises three times a day for effective joint health Waxy flexibility is an excessive and extended maintenance of posture that can lead to a variety of problems, including joint trauma. Passive range-of-motion exercises focus on the effective management of joint mechanics. Although aspiration precautions, documentation of intake and output, and staff role modeling may address issues experienced by a client with schizophrenia, passive range-of-motion exercises address waxy flexibility.
A client with schizophrenia says to the nurse, "I've been here 5 days. There are five players on a basketball team. I like to play the piano." How should the nurse document this cognitive disorder? Word salad Loose association Thought blocking Delusional thinking
Loose association These ideas are not well connected and there is no clear train of thought. This is an example of loose association. Word salad is incoherent expressions containing jumbled words. This client's thoughts are coherent but not connected. Thought blocking occurs when the client loses the train of thinking and ideas are not completed. Each of the client's thoughts is complete but not linked to the next thought. These statements are reality based and not reflective of delusional thinking
A young client with schizophrenia says, "I'm starting to hear voices." What is the nurse's most therapeutic response? "How do you feel about the voices, and what do they mean to you?" "You're the only one hearing the voices. Are you sure you hear them?" "The health team members will observe your behavior. We won't leave you alone." "I understand that you're hearing voices talking to you and that the voices are very real to you. What are the voices saying to you?
"I understand that you're hearing voices talking to you and that the voices are very real to you. What are the voices saying to you? Acknowledging that client is hearing voices talking to him and that the voices are very real to him validates the presence of the client's hallucinations without agreeing with them, which communicates acceptance and can form a foundation for trust; it may help the client return to reality. The nurse also needs to assess the content of the voices to determine the risk of self injury or violence against others. The client's contact with reality is too tenuous to explore what they mean. Saying that the client is the only one hearing the voices and asking whether he is sure that he is hearing demeans the client, which blocks the development of a trusting relationship and future communication. Telling the client that the health team members will observe his behavior and that he won't be left alone is condescending and may impair future communication.
A nurse is monitoring a client with the diagnosis of schizophrenia who is experiencing opposing emotions simultaneously. When providing a change-of-shift report, how should the nurse refer to this emotional experience of the client? Double bind Ambivalence Loose association Inappropriate affect
Ambivalence Ambivalence is the existence of two conflicting emotions, impulses, or desires. Double bind is two conflicting messages, not emotions, in a single communication. Loose associations are not two conflicting emotions but instead the loosening of connections between thoughts. Inappropriate affect is not two conflicting emotions but instead the inappropriate expression of emotions.
A nurse is assessing a client with chronic schizophrenia. Which effects will the client most likely exhibit? Select all that apply. Apathy Sadness Flatness Hostility Happiness Depression
Apathy Flatness Apathy (indifference) is common among people with chronic schizophrenia because negative symptoms are more apparent. Flatness, with few extremes of emotion, is common among people with chronic schizophrenia because negative symptoms are more apparent. Extremes in emotions are not associated with chronic schizophrenia. Sadness is related more to mood disorders, such as a depressive episode of bipolar disorder or major depression. Hostility may be seen in some forms of schizophrenia, such as paranoid schizophrenia, but it is rarely seen in the chronic stages. Happiness and elation are associated with manic episodes of bipolar disorder, not chronic schizophrenia. Depression is related to mood disorders, such as a depressive episode of bipolar disorder or major depression.
A 22-year-old male client with the diagnosis of schizophrenia has been in a mental health facility for approximately 2 weeks. After his parents visit he is seen pacing in the hall, talking loudly to himself. What should the nurse's initial intervention be? Obtaining a prescription for a tranquilizer Asking the client about the events of his day Calling the parents to find out what happened Assigning a nursing assistant to remain with the client
Asking the client about the events of his day A broad opening encourages communication that may elicit the client's perception of the day's events. Obtaining a prescription for a tranquilizer is premature. What is most important is the client's, not the parents', perception of what has occurred. Assigning a nursing assistant to remain with the client is premature; there are no data to indicate that the client may harm himself or others.
A newly admitted male client with schizophrenia appears to be responding to internal stimuli when laughing and talking to himself. What is the best initial response by the nurse? Asking the client whether he is hearing voices Encouraging the client to engage in unit activities Telling the client that the voices he is hearing are not real Giving the client his prescribed PRN antipsychotic medication
Asking the client whether he is hearing voices Because the client is newly admitted, the nurse needs to conduct a thorough assessment before intervening. Encouraging the client to engage in unit activities may eventually be done but is not the priority. Telling the client that the voices he is hearing are not real assumes that the client is hallucinating. The client's behavior does not indicate the need for extra medication at this time. Some clients with schizophrenia have hallucinations throughout their lives.
Breaks with reality such as those experienced by clients with schizophrenia require the nurse to understand that: Extended institutional care is necessary. Clients believe that what they feel that they are experiencing is real. Electroconvulsive therapy produces remission in most clients with schizophrenia. The clients' families must cooperate in the maintenance of the psychotherapeutic plan.
Clients believe that what they feel that they are experiencing is real. Failure to accept the client and the client's fears is a barrier to effective communication. Today mental health therapy is directed toward returning the client to the community as rapidly as possible. Electroconvulsive therapy is not the treatment of choice for clients with schizophrenia. Family cooperation is helpful but not an absolute necessity.
A client has been prescribed chlorpromazine (Thorazine) for the management of positive symptoms of schizophrenia. When the client reports difficulty sustaining an erection, the nurse: Reassures him this side effect will resolve in a few weeks Consults with his provider regarding alternative medication therapies Explains that all conventional antipsychotic medications cause impotence Provides additional medication education to explain the medication's side effects in detai
Consults with his provider regarding alternative medication therapies Although erectile dysfunction can result from conventional antipsychotic medication therapy, the provider is often able to prescribe an alternative medication that will help manage the symptoms but is less likely to cause the dysfunction. Education regarding side effects is certainly appropriate, but such information will only confirm that the side effect is not likely to subside with time.
One morning a client tells the nurse, "My legs are turning to rubber because I have an incurable disease called schizophrenia." The nurse identifies that this as an example of: Hallucinations Paranoid thinking Depersonalization Autistic verbalization
Depersonalization The state in which the client feels unreal or believes that parts of the body are distorted is known as depersonalization or loss of personal identity. This is not an example of a hallucination; a hallucination is a sensory experience for which there is no external stimulus. The client's statement does not indicate any feelings that others are out to do harm, are responsible for what is happening, or are in control of the situation. The statement is not an example of autistic verbalization.
A nurse is caring for a client with the diagnosis of schizophrenia. What is a common problem for clients with this diagnosis? Chronic confusion Disordered thinking Rigid personal boundaries Violence directed toward others
Disordered thinking The schizophrenic individual has neurobiological changes that cause disorders in thought process and perceiving reality. Chronic confusion and disorientation are not usually associated with this disorder. Illogical thinking and impaired judgment are associated with schizophrenia. Individuals with the diagnosis of schizophrenia often have personal boundary difficulties. They lack a sense of where their bodies end in relation to where others begin. Loss of ego boundaries can result in depersonalization and derealization. Most clients with schizophrenic disorders are not violent.
The night nurse reports that a young client with paranoid schizophrenia has been awake for several nights. The day nurse reviews the client's record and finds that this client did not have an interrupted sleep pattern disorder before transfer from a private room to a four-bed room 3 days ago. What factor should the nurse identify as most likely related to the client's sleeplessness? Fear of the other clients Concern about family at home Watching for an opportunity to escape Trying to work out emotional problems
Fear of the other clients Because the client has paranoid feelings that other people are out to do harm, assignment to a four-bed room may be threatening. Concern about family at home seems unlikely because the disruption appears to have started with the transfer to a four-bed room. Watching for an opportunity to escape is possible but unlikely; planning an escape is usually not part of a schizophrenic pattern of behavior. Trying to work out emotional problems is possible but not likely; clients with schizophrenia have difficulty solving problems.
A client with the diagnosis of schizophrenia refuses to eat meals. Which nursing action is most beneficial for this client? Directing the client repeatedly to eat the food Explaining to the client the importance of eating Waiting and allowing the client to eat whenever the client is ready Having a staff member sit with the client in a quiet area during mealtimes
Having a staff member sit with the client in a quiet area during mealtimes By sitting with the client during mealtimes the nurse can evaluate how much the client is eating; this encourages the client to eat and begins the construction of a trusting relationship. Fewer distractions may help the client focus on eating. The client will not follow directions to eat because of the nature of the illness. Explaining the importance of eating and allowing the client to eat when ready are both unrealistic and will not ensure adequate intake.
A young client is admitted to the hospital with a diagnosis of acute schizophrenia. The family reports that one day the client looked at a linen sheet on a clothesline and thought it was a ghost. What is the most appropriate conclusion to make about what the client was experiencing? Illusion Delusion Hallucination Confabulation
Illusion An illusion is a misinterpretation of an actual sensory stimulus. A delusion is a false, fixed belief. A hallucination is a false sensory perception that occurs with no stimulus. Confabulation is a filling in of blanks in memory.
A client with catatonic schizophrenia who is in a vegetative state is admitted to the psychiatric hospital. The nurse identifies short- and long-term outcomes in the client's clinical pathway. What is the priority short-term outcome of care that the client should be able to attain? Talking with peers Performing her own activities of daily living Completing unit activities and assignments Ingesting adequate fluid and food with assistance
Ingesting adequate fluid and food with assistance A client in a vegetative state may not eat or drink without assistance; fluids and foods are basic physiologic needs that are necessary to prevent malnutrition and starvation; therefore the intake of adequate fluid and food is a priority short-term goal. The client is in total withdrawal; talking with peers, performing activities of daily living, and completing activities and assignments are not priority outcomes at this time.
A client with schizophrenia, paranoid type, is delusional, withdrawn, and negativistic. The nurse should plan to: Invite the client to play a game of cards or board game. Explain to the client the benefits of joining a group activity. Encourage the client to become involved in group activities. Mention to the client that the psychiatrist has ordered increased activity.
Invite the client to play a game of cards or board game. Activities that require limited interpersonal contact are less threatening. Individuals with schizophrenia, paranoid type, usually do not respond to an authoritarian approach because they do not trust others, particularly those who act in an aggressive manner. Group activities require interaction with other people, which is threatening to individuals with paranoid feelings.
The nurse manager of a psychiatric unit informs the primary nurse that a client will be admitted to the unit within an hour. The client's admission diagnosis is paranoid schizophrenia. What classic clinical findings should the nurse anticipate? Select all that apply. Mutism Posturing Flat affect Extreme negativism Prominent delusions Auditory hallucinations
Prominent delusions Auditory hallucinations Prominent delusions are the essential feature of paranoid schizophrenia; delusions are typically persecutory, grandiose, or both, but delusions with other themes, such as jealousy, religiosity, or somatization, also may occur. Auditory hallucinations are a characteristic associated with paranoid schizophrenia; usually they are related to the delusional theme. Mutism is associated more commonly with the subtype of catatonic schizophrenia. Psychomotor retardation and posturing are associated with catatonic schizophrenia. A flat affect is associated more commonly with the subtype of disorganized schizophrenia. Extreme negativism is associated more commonly with the subtype of catatonic schizophrenia.
What should the nurse do when a client with the diagnosis of schizophrenia talks about being controlled by others? Express disbelief about the client's delusion. Divert the client's attention to unit activities. React to the feeling tone of the client's delusion. Respond to the verbal content of the client's delusion
React to the feeling tone of the client's delusion. Reacting to the feeling tone of the client's delusion helps the client explore underlying feelings and allows the client to see the message that his verbalizations are communicating. Expressing disbelief about the client's delusion denies the client's feelings rather than accepting and working with them. Attempting to divert the client rather than accepting and working with him denies the client's feelings. Responding to the verbal content of the client's delusion focuses on the delusion itself rather than on the feeling that is causing the delusion.
A client with the diagnosis of schizophrenia watches the nurse pour juice for the morning medication from an almost-empty pitcher and screams, "That juice is no good! It's poisoned." What is the most therapeutic response by the nurse? Assure the client, "The juice is not poisoned." Pour the client a glass of juice from a full pitcher. Take a drink of the juice to show the client that it is safe. Say, "You sound frightened. Is there something else I can give you to take your medication with?
Say, "You sound frightened. Is there something else I can give you to take your medication with? The response "You sound frightened" reflects the client's feelings and avoids focusing on the delusion; following up with "Is there something else I can give you to take your medication with?" encourages the client to take the medication. The response "The juice is not poisoned" will not change the client's feelings because the belief is real to the client. Pouring the client a glass of juice from a full pitcher will not change the client's feelings because the other pitcher also may be perceived as poisoned. Taking a drink of the juice to show the client that it is safe will not change the client's feelings; the client will believe that the nurse was not really drinking the juice.
An adult with the diagnosis of schizophrenia is admitted to the psychiatric hospital. The client is ungroomed, appears to be hearing voices, is withdrawn, and has not spoken to anyone for several days. What should the nurse do during the first few hospital days? See that the client bathes and changes clothes daily. Wait and see whether the client approaches the staff. Conduct an admission assessment interview with the client. Seek out the client frequently to spend short periods of time together.
Seek out the client frequently to spend short periods of time together. Seeking out the client frequently to spend short periods of time together will help the nurse establish trust without unduly increasing anxiety. Seeing that the client bathes and changes clothes daily is not the priority unless the client is extremely dirty; this client is ungroomed, not dirty. A withdrawn client will usually not approach anyone. The client's history reveals a failure to speak.
As a nurse is assisting a client with the diagnosis of schizophrenia with morning care, the client suddenly throws off the covers and starts shouting, "My body is disintegrating! I'm being pinched." What term best describes the client's behavior? Somatic delusion Paranoid ideation Loose association Ieas of referenc
Somatic delusion A somatic delusion is a false feeling about the physical self that is caused by a loss of reality testing. Paranoid ideations are beliefs that the individual is being singled out for unfair treatment. Loose associations are verbalizations that are difficult to understand because the links between thoughts are not apparent. Ideas of reference are false beliefs that the words and actions of others are concerned with or are directed toward the individual.
On the afternoon of admission to a psychiatric unit, an adolescent boy with the diagnosis of schizophrenia exposes his genitals to a female nurse. What should the nurse's immediate therapeutic response be? Ignoring the client at this time Stating that this behavior is unacceptable Moving him to his room for a short time-out Telling the client to come to the office later to discuss the behavior
Stating that this behavior is unacceptable When clients enter a new milieu, limits should be set on unacceptable behavior and acceptable behavior should be reinforced. Neither clients nor unacceptable behavior should ever be ignored. Moving the client to his room for a short time-out is punishment. Unacceptable attention-getting behavior must be addressed immediately; also, the focus should be on appropriate behavior
Which client characteristic is an initial concern for the nurse when caring for a client with the diagnosis of paranoid schizophrenia? Continual pacing Suspicious feelings Inability to socialize with others Disturbed relationship with the family
Suspicious feelings The nurse must consider the client's suspicious feelings and establish basic trust to promote a therapeutic milieu. Continual pacing is not a problem because the nurse can walk back and forth with the client. Inability to socialize with others and disturbed relationship with the family may be of long-range importance but have little influence on the nurse-client relationship at this time.
A client with schizophrenia is taking benztropine (Cogentin) in conjunction with an antipsychotic. The client tells a nurse, "Sometimes I forget to take the Cogentin." What should the nurse teach the client to do if this happens again? Take 2 pills at the next regularly scheduled dose. Notify the health care provider about the missed dose immediately. Take a dose as soon as possible, up to 2 hours before the next dose. Skip the dose, then take the next regularly scheduled dose 2 hours early.
Take a dose as soon as possible, up to 2 hours before the next dose. Taking a dose as soon as possible is the advised intervention when a dose is missed; interruption of the medication may precipitate signs of withdrawal such as anxiety and tachycardia. Taking 2 pills at the next regularly scheduled dose will provide an excessive amount of the medication at one time. Notifying the health care provider about the missed dose immediately is unnecessary. Skipping a dose is not advised if the next regularly scheduled dose is due within 2 hour
A client with chronic undifferentiated schizophrenia is receiving an antipsychotic medication. For which potentially irreversible extrapyramidal side effect should a nurse monitor the client? Torticollis Oculogyric crisis Tardive dyskinesia Pseudoparkinsonism
Tardive dyskinesia Tardive dyskinesia occurs as a late and persistent extrapyramidal complication of long-term antipsychotic therapy. It is most often manifested by abnormal movements of the lips, tongue, and mouth. The other side effects are reversible with administration of an anticholinergic (e.g., benztropine [Cogentin]) or an antihistamine (e.g., diphenhydramine [Benadryl]) or cessation of the medication.
A client with the diagnosis of schizophrenia is given one of the antipsychotic drugs. The nurse understands that antipsychotic drugs can cause extrapyramidal side effects. Which effect is cause for the greatest concern? Akathisia Tardive dyskinesia Parkinsonian syndrome Acute dystonic reaction
Tardive dyskinesia Tardive dyskinesia, an extrapyramidal response characterized by vermicular movements and protrusion of the tongue, chewing and puckering movements of the mouth, and puffing of the cheeks, is often irreversible, even when the antipsychotic medication is withdrawn. Akathisia, motor restlessness, usually can be treated with antiparkinsonian or anticholinergic drugs while the antipsychotic medication is continued. Parkinsonian syndrome (a disorder featuring signs and symptoms of Parkinson disease such as resting tremors, muscle weakness, reduced movement, and festinating gait) can usually be treated with antiparkinsonian or anticholinergic drugs while the antipsychotic medication is continued. Dystonia, impairment of muscle tonus, can usually be treated with antiparkinsonian or anticholinergic drugs while the antipsychotic medication is continued.
A client with paranoid schizophrenia tells the nurse, "My neighbors are spying on me because they want to rob me and take money." While hospitalized, the client complains of being poisoned by the food and of being given the wrong medication. The nurse evaluates the client's response to medications and therapy. Which assessment finding leads the nurse to conclude that the client's reality testing has improved? The client eats the food provided on the hospital tray. The client discusses his discharge plans with the staff. The client questions each medication when it is administered. The client asks permission to make phone calls to the hospital administration
The client eats the food provided on the hospital tray. Because the client was admitted while complaining that the food was poisoned, eating the food on the tray indicates that the client feels safe. Discussing discharge plans with the staff does not provide adequate behavioral assessment with which the nurse can evaluate reality testing. Questioning each medication when it is administered indicates that the client still does not completely trust the staff. Asking permission to make phone calls to the hospital administration seems to indicate that the client still does not trust the staff and is attempting to intimidate the staff by calling the administration.
By identifying behaviors commonly exhibited by the client who has a diagnosis of schizophrenia, the nurse can anticipate: Disorientation, forgetfulness, and anxiety Grandiosity, arrogance, and distractibility Withdrawal, regressed behavior, and lack of social skills Slumped posture, pessimistic outlook, and flight of ideas
Withdrawal, regressed behavior, and lack of social skills Withdrawal, regressed behavior, and lack of social skills are classic behaviors exhibited by clients with a diagnosis of schizophrenia. Disorientation, forgetfulness, and anxiety are more commonly associated with dementia. Grandiosity, arrogance, and distractibility are more commonly associated with bipolar disorder, manic phase. Slumped posture, pessimistic outlook, and flight of ideas are more commonly associated with depression.
A client with schizophrenia is actively psychotic, and a new medication regimen is prescribed. A student nurse asks the primary nurse, "Which of the medications will be the most helpful against the psychotic signs and symptoms?" What response should the nurse give? Citalopram (Celexa) Ziprasidone (Geodon) Benztropine (Cogentin) Acetaminophen with hydrocodone (Lortab)
Ziprasidone (Geodon) Ziprasidone (Geodon) is a neuroleptic, which will reduce psychosis by affecting the action of both dopamine and serotonin. Citalopram (Celexa) is a selective serotonin reuptake inhibitor antidepressant. Benztropine (Cogentin) is an anticholinergic. Acetaminophen with hydrocodone (Lortab) is an analgesic/opioid.
