EAQ Schizophrenia
What clinical manifestation best indicates to the nurse that the mental status of a client with the diagnosis of schizophrenia, paranoid type, is improving? 1 Absence of mild to moderate anxiety 2 Development of insight into the problem 3 Decreased need to use defense mechanisms 4 Ability to function effectively in activities of daily living
4 A person who can handle the activities of daily living and function in society is considered mentally stable. Some anxiety is necessary and unavoidable; anxiety causes problems when it is overwhelming for an extended period. Insight into one's problems is of no use if one is unable to function in society. Everyone uses defense mechanisms; the extent to which they are used helps determine mental health.
A client with paranoid schizophrenia wraps the legs in toilet paper, believing that this will provide protection from deadly germs contaminating the floor. What is the best nursing intervention? 1 Limiting the client's access to toilet paper 2 Providing the client with antimicrobial soap 3 Explaining to the client why this action is ineffective 4 Talking with the client about anxiety that focuses on health
4 Exploring the feelings expressed in the delusion is more therapeutic than discussing specific content. Limiting the client's access to toilet paper may frustrate the client, who will probably seek other ways of "protection." Providing the client with antimicrobial soap reinforces the client's delusion about deadly germs. Trying to talk this client out of the delusion will not be effective and may precipitate hostility.
A client's parents ask about the treatment of their child who has a recent diagnosis of schizophrenia. Before responding, what should the nurse consider? 1 Electroconvulsive therapy is more effective in treating schizophrenia than mood disorders. 2 Family therapy has not been proved effective in the treatment of clients with schizophrenia. 3 Insight therapy has been proved highly successful in the treatment of clients with schizophrenia. 4 Drug therapy, although it does not eliminate the underlying problem, reduces the symptoms of acute schizophrenia.
4 Psychoactive drugs have been shown to be capable of interrupting the acute psychiatric process, making the client more amenable to other therapies. Electroconvulsive therapy may be effective in treating depressed clients. Family therapy is effective but is a long-term, costly proposition; signs and symptoms must be reduced before the client can participate. Clients with schizophrenia usually have little insight into their problems. Confronting the client through insight therapy will increase anxiety.
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? 1 Illusion 2 Delusion 3 Hallucination 4 Confabulation
1 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.
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? 1 Fear of the other clients 2 Concern about family at home 3 Watching for an opportunity to escape 4 Trying to work out emotional problems
1 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 nurse is caring for a client with the diagnosis of schizophrenia. What should the nurse plan to do to increase the self-esteem of this client? 1 Reward healthy behaviors. 2 Explain the treatment plan. 3 Identify various means of coping. 4 Encourage participation in community meetings.
1 By realistically rewarding the healthy behaviors, the nurse provides secondary gains and encourages the continued use of healthy behaviors. Explaining the treatment plan, identifying various means of coping, and encouraging participation in community meetings are important but will do little to increase the client's self-esteem.
A client with schizophrenia reports having ongoing auditory hallucinations and describes them as "voices telling me that I'm a bad person" to the nurse. What is the best response by the nurse? 1 "Try to ignore the voices." 2 "What are the voices saying to you?" 3 "Do you believe what the voices are saying?" 4 "They're only voices, so just try not to be afraid."
1 Clients can sometimes learn to push auditory hallucinations aside, particularly within the framework of a trusting relationship; it may provide the client with a sense of power to manage the voices. Once it has been established by the nurse that the voices are not commanding the client to self-harm or harm others, focusing on the content of the hallucinations is not therapeutic. Asking whether the client believes what the voices are saying or encouraging the client not to be afraid of them is irrelevant to the situation; clients believe in and are frightened by hallucinations.
A client with schizophrenia plans an activity schedule with the help of the treatment team. A written copy is posted in the client's room. What should the nurse say when it is time for the client to go for a walk? 1 "It's time for you to go for a walk now." 2 "Do you want to take your scheduled walk now?" 3 "When would you like to go for your walk today?" 4 "You're supposed to be going for your walk now."
1 Telling the client that it is time to take a walk is concise and does not require decision-making; it is therefore less likely to increase anxiety. "Do you want to take your scheduled walk now?" asks the client to make a decision when a refusal is unacceptable. Requiring the client to make a decision when acutely ill may increase anxiety; also, it permits the unacceptable answer of "never." "You're supposed to be going for your walk now" is somewhat accusatory; it may increase anxiety by placing responsibility on the client.
The nurse is caring for a client with newly diagnosed schizophrenia. What factor in the client's history indicates a greater potential for recovery? 1 Vague prepsychotic symptoms 2 Brain abnormalities on PET scan 3 Insidious onset of the client's illness 4 A relative who also has schizophrenia
1 The presence of vague prepsychotic symptoms is associated with decreased morbidity related to schizophrenia. Brain abnormalities on PET scan, insidious onset of the client's illness, and a relative who also has schizophrenia tend to contribute to a poor prognosis.
A client with acute schizophrenia tells the nurse, "Everyone hates me." What is the best response by the nurse? 1 "Tell me more about this." 2 "Everyone does not hate you." 3 "That feeling is part of your illness." 4 "You may be promoting this feeling yourself."
1 The response "Tell me more about this" explores more fully the client's ideas, experiences, or relationships; this response promotes communication. Arguing about delusions increases anxiety and diminishes trust. The response "That feeling is part of your illness" denies the client's feelings and implies that the client is wrong; it may cause the client to defend the feelings further. The response "You may be promoting this feeling yourself" puts the blame on the client and implies that the feelings are based on reality.
A young adult client is admitted to the hospital with a diagnosis of schizophrenia, paranoid type. The client has been saying, "The voices in heaven are telling me to come home to God." What should initial nursing care be focused on? 1 Disturbed self-esteem 2 Potential for self-harm 3 Dysfunctional verbal communication 4 Impaired perception of environmental stimuli
2 Client safety always is the priority over any other client need, and command hallucinations increase the risk of injury. Although promoting self-esteem is important, this is not a priority at this time. There are no data to support the need to focus on the client's ability to verbally communicate. Verbal hallucinations occur within the individual; they are not precipitated by an environmental stimulus.
When a nurse enters a room to administer an oral medication to an agitated and angry client with schizophrenia, paranoid type, the client shouts, "Get out of here!" What is the most therapeutic response? 1 Stating, "You must take your medicine now." 2 Saying, "I'll be back in a few minutes so we can talk." 3 Explaining why it is necessary to take the medication 4 Withholding the medication before notifying the primary healthcare provider
2 Saying, "I'll be back in a few minutes so we can talk" allows the angry client time to regain self-control; announcing a plan to return will ease fears of abandonment or retribution. Staying and insisting that the client take the medication may provoke increased anger and further loss of control. Clients will not accept logical explanations when angry. Alternative nursing interventions should be attempted before withholding the medication and notifying the primary healthcare provider, although these may become necessary.
A nurse who is working on a psychiatric unit notes that a client with schizophrenia is beginning to pace around the lounge while glaring at other clients. How should the nurse respond to this behavior? 1 By pointing out the behavior to the client 2 By walking with the client to a quiet area on the unit 3 By suggesting that the client go to the gym to work out 4 By arranging for an additional staff member to be present in the vicinity of the client
2 The client is demonstrating signs of agitation, and stimuli from the environment must be reduced. Pointing out the behavior is confrontational and may increase the client's agitation. The client should not be left unattended at this time; aggressive physical activity at this time may increase the agitation. Arranging for the presence of another staff member will not interrupt the client's behavior, which is the priority at this time. 69%of students nation
A client with schizophrenia is admitted to a psychiatric unit. The client is talking while walking in the hall, is unkempt, and obviously has not washed in several days. What should the nurse say when trying to help this client shower? 1 "Would you like a shower?" 2 "I'll help you take your shower now." 3 "When do you want your shower, now or later?" 4 "You'll feel so much better if you have a shower."
2 The client is displaying a self-care deficit; stating the intention of helping the client shower is direct, does not require the client to make a decision, provides help, and meets the client's physiologic and psychological needs. The client may or may not be capable of making a decision; if the client says no, the nurse will be confronted with a dilemma: meeting the client's physiologic needs will contradict the client's wish not to bathe. The client may not be able to tell the nurse when the shower is desired, because the client may be incapable of making a decision. "You'll feel so much better if you have a shower" may be false reassurance; the client may not be able to process cause and effect.
Which client characteristic is an initial concern for the nurse when caring for a client with the diagnosis of paranoid schizophrenia? 1 Continual pacing 2 Suspicious feelings 3 Inability to socialize with others 4 Disturbed relationship with the family
2 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 a diagnosis of schizophrenia, undifferentiated type, was admitted to the mental health hospital 3 days ago. The client stays in the bedroom except to eat and has no verbal interaction with other clients. When the nurse approaches, the client walks away and says, "Just leave me alone." What is the best response by the nurse? 1 "We need to talk." 2 "I'll talk to you later." 3 "What are you angry about?" 4 "Is there a reason to be so upset?"
2 The response "I'll talk to you later" allows the client to have the choice of communicating and leaves channels of communication open. The response "We need to talk" does not provide for any choice by the client. The response "What are you angry about?" assumes that the nurse knows the client's feelings; the nurse should not make this assumption. "Is there a reason to be so upset?" is a judgmental response; the nurse should not make the assumption that the client is upset.
A client with the diagnosis of schizophrenia who has been hospitalized on a mental health unit for 2 weeks is to be discharged home. The client is vacillating between being happy and sad about going home. What term best describes these conflicting emotions? 1 Double bind 2 Ambivalence 3 Loose association 4 Inappropriate affect
2 The simultaneous existence of two conflicting emotions, impulses, or desires is known as ambivalence. A single communication containing two conflicting messages is known as a double-bind message. A lack of connections between thoughts is known as loose associations. Inappropriate affect is not two conflicting emotions but instead the inappropriate expression of emotions.
A nurse is caring for a client with the diagnosis of schizophrenia, paranoid type. What should the nurse plan for the client's initial care? 1 Discussing important life events 2 Providing a nonthreatening environment 3 Concentrating on the content of delusions 4 Limiting topics for discussion to recent situations
2 These clients are hypersensitive to external stimuli and respond with less anxiety to a minimally threatening environment. Discussing prominent life events is too threatening an approach and interferes with the goals of therapy. Focusing on delusional material will reinforce the delusional system. Limiting topics for discussion to recent situations is not therapeutic; it may trigger suspiciousness and hostile outbursts.
A nurse is assessing an adolescent client with the diagnosis of schizophrenia, undifferentiated type. Which signs and symptoms should the nurse expect the client to experience? 1 Paranoid delusions and hypervigilance 2 Depression and psychomotor retardation 3 Loosened associations and hallucinations 4 Ritualistic behavior and obsessive thinking
3 Loosened associations and hallucinations are the primary behaviors associated with a thought disorder such as schizophrenia. Paranoid delusions and hypervigilance are more common in paranoid-type schizophrenia than in the undifferentiated type. Depression and psychomotor retardation are not characteristic of schizophrenia. Ritualistic behavior and obsessive thinking are generally associated with obsessive-compulsive disorders, not schizophrenia.
A client with the diagnosis of schizophrenia, paranoid type, is admitted to the hospital. The client says to the nurse, "I know they're spying on me in here, too. I'm not safe anywhere!" What is the most therapeutic response by the nurse? 1 "Nobody's spying on you in here." 2 "Why do you feel they'd want to follow you here?" 3 "You don't feel safe anywhere, not even in the hospital?" 4 "You're safe in the hospital; nothing can happen to you here."
3 Rephrasing facilitates further communication, helps the nurse express understanding, and does not belittle the client's feelings. Presenting reality to the client at this time will only increase the client's anxiety and lead the client to defend the delusion. "Why" questions make a client defensive, and the wording implies that the client's delusion is true. Saying the client is safe constitutes false reassurance; also, a suspicious client will not believe the nurse.
A client with the diagnosis of schizophrenia refuses to get out of bed and becomes upset. What is the nurse's initial therapeutic response? 1 Requiring the client to get out of bed at once 2 Allowing the client to stay in bed for a while 3 Staying at the bedside until the client calms down 4 Giving the prescribed as-needed tranquilizer to the client
3 Staying at the bedside until the client calms down provides support and security without rejecting the client or placing value judgments on behavior. Eventually limits will have to be set, but this is not the immediate nursing action. Allowing the client to stay in bed for the time being ignores the problem, and isolation may imply punishment. Although medication will calm the client, it does not address the problem.
A young client with schizophrenia says, "I'm starting to hear voices." What is the nurse's most therapeutic response? 1 "How do you feel about the voices, and what do they mean to you?" 2 "You're the only one hearing the voices. Are you sure you hear them?" 3 "The health team members will observe your behavior. We won't leave you alone." 4 "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?"
4 Acknowledging that client is hearing voices and that the voices are very real to the client 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 the voices mean. Saying that the client is the only one hearing the voices and asking whether the client is sure the voices are being heard demeans the client, which blocks the development of a trusting relationship and future communication. Telling the client that the health team members will observe the behavior and that the client won't be left alone is condescending and may impair future communication.
After treatment, an adolescent with a history of schizophrenia improves and is to be discharged. The parents tell the nurse that they are concerned about how to respond "if our child starts to act crazy." What is the most therapeutic response by the nurse? 1 Teaching the parents how to respond to their child's bizarre behavior 2 Assuring the parents that they are capable of controlling their child's behavior 3 Referring the parents to a self-help group of parents with schizophrenic children 4 Having the parents discuss mutual concerns with their child before the discharge date
4 Both the parents and their child should be included in a discussion so that concerns can be addressed openly; this increases trust and fosters a good relationship. Teaching the parents how to respond to their child's bizarre behavior is not expected to be needed for a client who is ready to be discharged. Assuring the parents that they are capable of controlling their child's behavior is false reassurance. There is no evidence of the parents' ability to control their child's behavior. Referring the parents to a self-help group of parents with schizophrenic children may be useful for the family later, but it will not address the immediate problem.
A client with schizophrenia tells the nurse, "There are foreign agents conspiring against me; they're out to get me at every turn." How should the nurse respond? 1 "It must be scary to believe that people are out to trick you at every opportunity." 2 "Those people you call foreign agents are out to do you in. What else is happening?" 3 "What's happened to make you believe that these people you call foreign agents are after you?" 4 "I can understand how frightening your thoughts are to you, but there are not foreign agents out to get you."
4 Noting how frightening the client's thoughts must seem but also telling the client that the thoughts do not seem factual acknowledges the client's feelings and points out reality. Although "It must be scary to believe that people are out to trick you at every opportunity" is an empathic response, it does not point out reality; the word "trick" does not have the same connotation as "do me in." The response "Those people you call foreign agents are out to do you in. What else is happening?" reinforces the client's delusional system. The response "What's happened to make you believe these people you call foreign agents are after you?" does not focus on feelings and places the client on the defensive.
A male client with the diagnosis of schizophrenia, paranoid type, often displays overt sexual behavior toward female clients and nurses. What is the nurse's best response when the client engages in sexually explicit behavior? 1 Refusing to speak with the client until he stops the behavior 2 Sending the client to his room when the behavior is observed 3 Ignoring this behavior until the client is more in control of his responses 4 Telling the client in a matter-of-fact manner that his behavior is unacceptable
4 Telling the client that the behavior is unacceptable rejects the behavior, not the client; it helps separate the client from the behavior. Refusing to speak with the client does not help the client learn self-control; it rejects both the client and the behavior. Isolating the client limits his ability to learn more acceptable responses. Part of recovery is learning acceptable behavior; ignoring inappropriate behavior is not therapeutic.
After 2 days on the unit a client with the diagnosis of schizophrenia refuses to take a shower. What is the most appropriate intervention by the nurse? 1 Having the staff give the client a shower 2 Simply stating that the client must shower now 3 Gently pointing out that the client's appearance is upsetting the other clients 4 Gently asking whether the client would wash the hands and face if given a basin of water
4 The client needs to feel comfortable in the environment before establishing enough trust to undress for showering; the nurse's statement allows the client to make the decision. Stating that the client must shower now or having the staff give the client a shower may add to the client's anxiety and feelings of loss of control; it may also worsen any delusional thoughts the client is having. Gently pointing out that the client's appearance is upsetting the other clients will not help the client's self-image, and it does not matter what other clients think.
A client with a history of schizophrenia attends the mental health clinic for a regularly scheduled group therapy session. The client arrives agitated and exhibits behaviors that indicate that the client is hearing voices. When a nurse begins to walk toward the client, the client pulls out a large knife. What is the best approach by the nurse? 1 Firm 2 Passive 3 Empathetic 4 Confrontational
1 A firm approach prevents anxiety transference and provides structure and control for a client who is out of control. A passive approach for a client who may be out of control does not provide structure, which may increase the client's anxiety. Although the nurse should always base a therapeutic response on empathy, an obviously empathetic response may indicate to the client that the behavior is acceptable. A confrontational approach in this situation may escalate the client's agitation and precipitate further acting out.
A nurse is preparing a teaching plan to educate a relative of a client with schizophrenia about the early signs of relapse. What signs should the nurse plan to include? Select all that apply. 1 Appearing disheveled 2 Socializing with peers 3 Staying alone in the house 4 Joining a local church singing group 5 Exhibiting indifference to family activities
1, 3, 5 Appearing disheveled, a negative sign, may indicate schizophrenic relapse, because the individual does not have the interest or energy to complete the activities of daily living. Staying at home alone can be a sign of mental illness relapse, because the individual is becoming isolated and not socializing. Indifference to family activities may indicate mental illness relapse, because it may reflect feelings of apathy or a lack of emotional energy to become involved with others. Socializing with peers is a sign of mental health, because the individual is interacting with others; humans are highly social beings. Joining a church singing group indicates mental health, because the individual is interacting with others and is interested in an activity
. A client is admitted to a psychiatric unit with the diagnosis of schizophrenia, undifferentiated type. When assessing the client, the nurse identifies the presence of several characteristics related to this disorder. What may this include? Select all that apply. 1 Bizarre behavior 2 Extreme negativism 3 Disorganized speech 4 Persecutory delusions 5 Auditory hallucinations
1, 3, 5 Bizarre behavior, disorganized speech, and auditory hallucinations are associated with undifferentiated schizophrenia. Extreme negativism is associated with catatonic schizophrenia. Persecutory delusions are associated with paranoid schizophrenia.
A 22-year-old client with the diagnosis of schizophrenia has been in a mental health facility for approximately 2 weeks. After the parents visit the client is seen pacing in the hall, talking loudly alone. What should the nurse's initial intervention be? 1 Obtaining a prescription for a tranquilizer 2 Asking the client about the events of the day 3 Calling the parents to find out what happened 4 Assigning a nursing assistant to remain with the client
2 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 self-harm or harm others.
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? 1 Double bind 2 Ambivalence 3 Loose association 4 Inappropriate affect
2 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 the inappropriate expression of emotions.
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? 1 Word salad 2 Loose association 3 Thought blocking 4 Delusional thinking
2 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 client with schizophrenia uses the word "worriation" when talking with the nurse. How should the nurse respond? 1 By correcting the pronunciation of the word 2 By asking for clarification of the word's meaning 3 By ignoring its use while interacting with the client 4 By telling the client to use words that everyone can understand
2 This is an example of a neologism, a self-coined word whose meaning is known only to the client. It is not a mispronunciation. The word's meaning must be explored. The use of a neologism should not be ignored, because the word usually has significance to the individual who is using it. Telling the client to use words everyone else can understand is a demeaning response that may cut off communication.
Schizophrenia is associated with both positive and negative symptoms. While assessing a client with schizophrenia, the nurse notes that the client is experiencing positive symptoms; what does the nurse observe that leads to this conclusion? Select all that apply. 1 Poverty of speech 2 Agitated behavior 3 Lack of motivation 4 Delusions of grandeur 5 Auditory hallucinations
2, 4, 5 Agitated and restless behaviors are positive symptoms of schizophrenia. A delusion is a fixed false belief that is resistant to reasoning; when a person believes that he or she is a famous, historical or fictional omnipotent character this is called a delusion of grandeur; a delusion is a positive symptom associated with schizophrenia. An auditory hallucination is a sensory perception involving the sense of hearing that occurs in the absence of an external stimulus and is a positive symptom associated with schizophrenia. Decreased verbalization, including a sudden stoppage in the flow of speech (blocking) and lack of inflection, is a negative symptom associated with schizophrenia. Lack of motivation (avolition) and apathy are negative symptoms associated with schizophrenia.
A client with schizophrenia is going to occupational therapy for the first time. The client doesn't want to go and tells the nurse so. What is the most therapeutic initial response by the nurse? 1 "It's only for an hour, and then you'll be back." 2 "Try it once. If you don't like it, you don't have to go back." 3 "Tell me what concerns you about going to occupational therapy." 4 "Your primary healthcare provider prescribed it as part of your treatment. You should go."
3 "Tell me what concerns you about going to occupational therapy" is an open-ended statement that allows the nurse to explore the client's concerns. If the client would feel more comfortable having the nurse go with the client to the first session, this idea may be explored next. The statement "It's only for an hour, and then you'll be back" will do nothing to allay the client's anxiety about facing a new situation. Telling the client to try it once and that the client won't have to go back is not true; even if the client does not like the therapy, the client should be encouraged to go as part of the overall therapy program. Telling the client that the primary healthcare provider has prescribed the therapy as part of the treatment and that the client should go will do nothing to allay the client's anxiety about facing a new situation.
A client who has been hospitalized with schizophrenia tells the nurse, "My heart has stopped and my veins have turned to glass!" What should the nurse conclude that the client is experiencing? 1 Echolalia 2 Hypochondriasis 3 Somatic delusion 4 Depersonalization
3 A somatic delusion is a fixed false belief about one's body. Echolalia is the automatic and meaningless repetition of another's words or phrases. Hypochondriasis is a severe, morbid preoccupation with an unrealistic interpretation of real or imagined physical symptoms. Depersonalization is a feeling of unreality and alienation from one's self.
One morning a client with the diagnosis of schizophrenia claims to be Joan of Arc about to be burned at the stake. What is the most therapeutic response by the nurse? 1 "Tell me more about being Joan of Arc." 2 "We both know that you're not Joan of Arc." 3 "It seems like the world is a pretty scary place for you." 4 "You're safe here, because we won't let you be burned."
3 With the statement "It seems like the world is a pretty scary place for you" the nurse attempts to understand the symbolism, reflects and acknowledges the client's feelings, and helps preserve the client's integrity. The statement "Tell me more about being Joan of Arc" validates the client's delusion and does not test reality. The statement "We both know that you're not Joan of Arc" rejects the client's feelings and does not address the client's fears of being harmed; clients cannot be argued out of delusions. The statement "You're safe here, because we won't let you be burned" is false reassurance; the nurse cannot fully understand the symbolism and therefore cannot make this promise.
A client with schizophrenia is observed sitting alone quietly talking. The client appears sad and is tearful. Place the following nursing assessment questions in the appropriate order to best ensure client safety. 1. "What do you usually do to make the voices stop?" 2. "What are the voices telling you?" 3. "Are you hearing voices?" 4. "Are you thinking about hurting yourself or someone else?"
3, 2, 4, 1 Confirming that the client is experiencing verbal hallucinations is the priority. Determination of the nature of the message that the voices are delivering takes place next. The risk for injury to the client and others is assessed after the focus of the hallucination is identified. Finally the nurse will assist the client in managing the reaction to the hallucination.
While speaking with a client with schizophrenia, the nurse notes that the client keeps interjecting sentences that have nothing to do with the main thoughts being expressed. The client asks whether the nurse understands. What is the best response by the nurse? 1 "You aren't making any sense; let's talk about something else." 2 "You're so confused; I can't understand what you're saying to me." 3 "Why don't you take a rest? We can talk again later this afternoon." 4 "I'd like to understand what you're saying, but I'm having difficulty following you."
4 The statement "I'd like to understand what you are saying, but I'm having difficulty following you" lets the client know the nurse is trying to understand; it increases the client's self-esteem and points out reality. Clients with schizophrenia have problems with associative links, and these same problems will occur regardless of the topic. The statement "You're so confused; I can't understand what you're saying to me" and telling the client to take a rest and promising to talk about the client's concerns again later in the day cut off communication and tell the client that the nurse will speak only if the client's communication makes sense
A client with schizophrenia is demonstrating waxy flexibility. Which intervention is the best way to manage the possible outcome of this behavior? 1 Providing thickened liquids to minimize the risk of aspiration 2 Documenting intake and output each shift to monitor hydration 3 Reinforcing appropriate social boundaries through staff role modeling 4 Performing passive range-of-motion exercises three times a day for effective joint health
4 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.
