HESI Case Study: Schizophrenia Sam Harris

The nurse asks Sam if he has any allergies to medications. He reports an allergy to haloperidol (Haldol). The nurse asks him to describe the type of reaction he experienced. Sam states, "My neck got real stiff, and I couldn't move it." What type of reaction should the nurse expect? Akathisia. Dystonia. Parkinsonism. Synergistic.

Dystonia Dystonia is acute, tonic muscle spasms, often of the tongue, jaw, eyes, and neck but sometimes of the whole body. These spasms sometimes occur during the first few days of antipsychotic administration.

The nurse recalls that the atypical antipsychotics have different side effects than traditional antipsychotics. Which side effects are characteristic of atypical antipsychotics? SAA Increased tardive dyskinesia. Less incidence of weight gain. Fewer extrapyramidal effects. More extrapyramidal effects. Dry mouth.

Fewer extrapyramidal effects Dry mouth

The nurse understands that a client with Schizophrenia will experience which benefit from fluphenazine decanoate (Prolixin decanoate) if it is administered intramuscularly? Prevent more extrapyramidal side effects. Maintain long-term medication compliance. Minimize side effects from benztropine (Cogentin). Prevent risk of cardiac or renal disease.

Maintain long-term medication compliance Prolixin decanoate is a long-acting medication that is administered as an injection every 7 to 28 days to promote compliance with the medication regimen.

What will be the most important group activity to promote wellness in the community? Explore symptom management. Review education about medications. Practice social skills. Identify community coping resources.

Explore symptom management Symptom management exploration is an important activity for clients with schizophrenia so that relapse can be prevented. Clients often continue to experience symptoms such as hallucinations while living in the community.

One client in the group asks, "Why do we need to know about symptom triggers?" Which explanations are best? Select all that apply Knowing symptom triggers and how to manage them can help prevent relapse. Identifying symptom triggers may prevent the risk of violence and promote safety. Managing symptom triggers promotes communication with your caseworker. Keeping informed about triggers allows you to increase your medications immediately. Reducing exposure to triggers helps improve the client's prognosis by minimizing relapses.

Knowing symptom triggers and how to manage them can help prevent relapse. Identifying Symptom triggers may prevent the risk of violence and promote safety. Reducing exposure to triggers helps improve the client's prognosis by minimizing relapses.

Since most of the clients in the group have schizophrenia, the nurse leader decides to talk about symptom triggers in the final group session. How should the nurse explain symptom triggers to the clients? Symptom triggers are stressors that lead to increased difficulty handling anger. Symptom triggers can be related to health, the environment, or attitudes. Symptom triggers are behaviors that lead to medication noncompliance. Symptom triggers are stressors caused by hospitalization.

Symptom triggers can be related to health, the environment, or attitudes Symptom triggers are stimuli, or combinations of stimuli, and stressors that precede a new episode of the illness. These triggers can be related to nutrition, lack of sleep, fatigue, housing difficulties, changes in life events, and feeling overpowered, for example.

The nurse understands that an atypical antipsychotic like olanzapine (Zyprexa) requires what period of time to reach a steady state? 2 weeks. 4 or more weeks. 1 week. 2 days.

1 week

During reassessment of the client, the nurse notices that Sam sometimes pauses and mumbles something quietly to himself. He tilts his head to one side and then returns his attention to the nurse. What is the best response by the nurse? What are you thinking right now? Tell me about how you're feeling. Are you hearing any voices? I notice that you talk to yourself.

Are you hearing any voices? When the client tilts his head to one side, it is a nonverbal cue that he is hearing voices. The nurse should assess for the presence of auditory hallucinations.

A behavioral intervention that the nurse plans to teach the clients includes ways to cope with symptoms such as hallucinations and delusions. Which strategy is best for clients who hear voices? Avoid certain situations. Smoke more cigarettes. Decrease caffeine use. Take more medication.

Avoid certain situations Avoiding situations that increase symptoms can be helpful to minimize symptoms. Other general strategies include distraction, help seeking, or attempts to feel better such as taking a shower or performing relaxation exercises.

Which nursing assessment accurately describes Sam's lack of energy? Apathy. Anhedonia. Avolition. Affective.

Avolition Avolition is a lack of energy or drive.

Which data is most important to obtain before Sam begins the Zyprexa, which is an atypical antipsychotic? Baseline weight. Orthostatic blood pressure. Complete blood count. Screening for tardive dyskinesia.

Baseline weight Weight gain occurs with the atypical antipsychotics, especially Zyprexa (olanzapine) and clozapine (Clozaril).

Which behavior is characteristic of a thought disorder? Blunted affect. Irritability. Lability of mood. Preoccupation with guilty feelings.

Blunted affect A blunted or flat affect can occur as part of the negative or "soft" symptoms associated with a thought disorder. It can also occur with a mood disorder.

Which medication with potentially life-threatening side effects should the nurse expect the healthcare provider to prescribe for clients who do not respond to the use of other antipsychotics? Clozapine (Clozaril). Haloperidol decanoate (Haldol decanoate). Fluphenazine decanoate (Prolixin decanoate). Perfenazine (Trilafon).

Clozapine When a client has failed to respond to antipsychotic medications or long-acting antipsychotics, clozapine (Clozaril) may be initiated. Clozaril is used for clients with schizophrenia who have not responded to other antipsychotics. The potentially serious side effect of agranulocytosis requires that WBC counts be done weekly or every 2 weeks.

One week later, Sam has achieved the long-term goal to be free of delusions, and he has attended the wellness group to promote wellness in the community. Sam's community case worker has been contacted about the discharge plans and the need for transportation to Sam's apartment. What is the greatest benefit of a caseworker for this client? Coordinate services for Sam. Make sure Sam takes his medications. Empower Sam to be independent. Provide guidance for disability income.

Coordinate services for Sam. The greatest benefit of the case worker is to coordinate services related to housing, finances, and medical appointments, for example.

How should the nurse interpret Sam's belief that he is a famous movie star and that a limousine driver will arrive to get him later in the day?

Delusional thoughts Responding to the underlying feelings rather than the illogical content of the delusion will encourage discussion of fears, anxiety, and anger about hospitalization, without assuming that the delusion is right or wrong.

What is the most accurate assessment if the client believes that the healthcare providers are FBI agents and that there are cameras in his apartment to monitor his moves? Hallucinations. Delusions. Confabulation. Thought broadcasting.

Delusions Delusions are fixed, false beliefs that the nurse should avoid trying to logically disprove to the client.

What is the reason that Prolixin is prescribed for this patient? Disorganized thoughts. Difficulty sleeping at night. Feelings of depression. Stabilize client's mood.

Disorganized thoughts Antipsychotic medications are useful to manage symptoms related to cognitive impairment such as delusions and/or hallucinations, as well as behaviors related to agitation and aggression.

Which nursing problem has priority? Ineffective community coping. Disturbed thought processes. Sensory-perceptual disturbance. Ineffective denial.

Disturbed thought processes Disturbed thought processes is a priority problem because Sam is delusional.

Because Sam was violent with his father prior to admission, another long-term goal is that the client will not verbalize the desire to harm himself or others. Which statement will assist the nurse to assess if this goal has been met? Do you have a history of violence? Tell me about the relationship with your father. How do you feel about your father now? Do you think about hurting anyone now?

Do you think about hurting anyone now?

Based on this assessment, what is the most important nursing intervention? Establish rapport and trust. Assess for hallucinations. Maintain adequate social space. Plan to give a PRN antipsychotic.

Establish rapport and trust The most important intervention for a client who is suspicious and guarded is to establish rapport and trust. When clients have cognitive disorders and difficulty processing language, the beginning of trust is more readily established through nonverbal communication.

Which finding depicts negative symptoms of schizophrenia? Difficulty sitting still. Rapid and disorganized speech. Flat affect and social inattentiveness. Delusional statements.

Flat affect and social inattentiveness Flat affect and social inattentiveness, or "spaciness," are examples of negative symptoms characteristic of schizophrenia.

Which side effects would the nurse most likely observe with fluphenazine (Prolixin), a traditional antipsychotic? High extrapyramidal effects, low anticholinergic effects. High anticholinergic effects and low extrapyramidal effects. Risk for agranulocytosis, fever, and elevated blood pressure. Blood dyscrasias such as thrombocytopenia.

High extrapyramidal effects, low anticholinergic effects. Traditional antipsychotics generally have high extrapyramidal effects and low anticholinergic effects.

After implementing the first step, what step is taken next? Identify current ways to manage symptoms. Talk about specific support systems. Discuss other ways to manage symptoms. Develop a new symptom management plan.

Identify current ways to manage symptoms After the client has identified problem symptoms, the client should then identify current symptom management techniques and specific support systems and discuss other ways to manage symptoms.

The nurse plans to teach the group members about symptom management techniques. What is the first step the nurse should use to teach about effective symptom management?

Identify problem symptoms Identifying problem symptoms is the first step of effective symptom management

In planning this client's care, what is the most important short-term client outcome? Interact without expressing delusional thoughts. Create a support network within the community. Identify at least one symptom management technique. Identify actions to take to prevent relapse.

Interact without expressing delusional thoughts When a client is delusional, interacting without expressing delusional thoughts is an important short-term outcome. As the client gains insight into the symptoms, the client can differentiate experiences with delusions from those that are reality.

How should the nurse respond?

It sounds like you are anxious to leave here. Responding to the underlying feelings rather than the illogical content of the delusion will encourage discussion of fears, anxiety, and anger about hospitalization, without assuming that the delusion is right or wrong.

Relapse Prevention The nurse plans to talk about relapse prevention. What is the most common cause of relapse in a client with schizophrenia? Symptom management. Medications. Lack of community support. Health practices.

Medications The most common causes of relapse relate in some way to medications. Relapse is likely to occur whether the client is taking medications or not, especially if the client has poor health practices.

The nurse understands that schizophrenia can be differentiated from psychosis by which assessment? Disorganized speech. Disorganized behavior. Auditory hallucinations. Negative symptoms.

Negative symptoms Negative symptoms are characteristic of schizophrenia and include behaviors such as minimal eye contact, poor grooming and hygiene, and apathy.

Which nursing action is best?

Obtain a prescription to begin the Cogentin. The nurse should request a prescription for Cogentin, which will help prevent the extrapyramidal side effects of the Prolixin, with the exception of tardive dyskinesia. There is a risk of decreased efficiency of Prolixin when the client is also taking Cogentin.

After 96 hours of involuntary commitment, a client must be asked to sign consent for hospitalization. If a client who has voluntarily chosen to be hospitalized should want to leave the hospital, which assessment would be most important in deciding to release the client against medical advice (AMA)? Mental status of client. Reason that client wants to leave. Response to medications. Potential danger to self or others.

Potential danger to self or others Potential danger to self and others is the most important consideration when a client wants to leave the hospital.

Which speech process should the nurse document on the daily mental status exam record? Loose associations. Tangential. Monotone. Poverty of speech.

Poverty of speech A client who demonstrates poverty of speech gives simple one- or two-word answers to questions, even when the nurse asks an open-ended question.

Sam agrees to participate in a group that is scheduled to last for 3 weeks. He remains attentive and responds to questions when asked. During the first group he shares, "The medications cause too many side effects. I have been taking them for a long time." Based on Sam's statement, which nursing problem should the nurse document for the group progress note? Ineffective denial. Knowledge deficit. Ineffective coping. Risk for adherence.

Risk for adherence Risk for adherence is evident because if the client perceives that the medication has too many side effects, he may choose to stop taking it.

Which nursing problem should be included on the treatment plan? Impaired adjustment. Social isolation. Anxiety. Confusion.

Social isolation Social isolation is manifested by behaviors such as the client sitting alone continuously without interacting with others.

Sam smiles at the nurse but refuses to answer. Group Therapy On the third day of hospitalization, the nurse must assign Sam to one of the unit groups. Which group is most therapeutic for Sam? Structured medication group. Unstructured group about personal issues. Psychoeducational group about self-esteem. Supportive therapy group.

Structured medication group A structured medication group is the most therapeutic because clients with schizophrenia have concrete thinking processes and will respond best to structured activities. Groups that support medication education are important to promote medication compliance.

Which intervention by the nurse will best assess if this goal has been met? Observe sam for signs of talking to himself. Talk to Sam for at least 20 minutes. Ask Sam to describe how he feels. Ask Sam to explain how the medication helps him.

Talk to Sam for at least 20 minutes The nurse should be able to talk to the client without observing the presence of delusional thoughts.

Which understanding is most accurate? There is an imbalance of the brain neurotransmitters dopamine and serotonin. There is a marked increase in brain volume, which causes abnormal functioning. Schizophrenia develops when at least one parent or distant relative has schizophrenia. This brain disorder has many predisposing factors and a biological basis.

This brain disorder has many predisposing factors and a biological basis Schizophrenia is a brain disorder with many predisposing factors. These factors include biological factors related to genetics, neurobiology, neurotransmitters, and neurodevelopment of structural, functional, and chemical brain changes that occur in early years of life and before birth.

A client in the wellness group states that he was taking his medications every day and started hearing voices more and had to be hospitalized. What is the nurse's best response? This can happen even if you are taking medications every day. Maybe you forgot to take some of your medication. How long have you been taking your medications? Compliance with medications will prevent relapse.

This can happen even if you are taking medications every day? The nurse should explain that relapse can occur even if the client has been taking medications as prescribed.

When the nurse asks Sam to share one goal for the day in community meeting, he states, "I'm going to take a shower and . . ." He pauses for several seconds and begins talking again. Which thought process does this exemplify?

Thought blocking Thought blocking is the sudden stopping in the client's train of thought or in the middle of a sentence.

Which client behavior validates the need for involuntary hospitalization? Beliefs about FBI surveillance. Diagnosis of schizophrenia. Violence towards father. Guarded and suspicious.

Violence towards father Risk for violence toward self or others is a criterion for involuntary hospitalization.