Chapter 16: Schizophrenia

A client diagnosed with schizophrenia tells the nurse, "I hear the voice of Elvis." Which is the most therapeutic response by the nurse?

"I don't hear the voice, but I know you hear what sounds like a voice." Acknowledging that the client hears what sounds like a voice states reality about the client's hallucination. The other options are judgmental and demeaning. Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, p. 283.

A client with schizoaffective disorder is prescribed clozapine to treat symptoms. Which instructions would the nurse provide?

"Keep an eye on your weight, and if you gain weight rapidly, notify your doctor." The client should be cautioned to notify the health care provider if the client has rapid weight gain because this may be indicative of excessive fluid retention. Dry mouth and sedation, common side effects of any antipsychotic agent, do not require the client to notify the physician. Urinary changes are not associated with clozapine use. Although clozapine is associated with an increased risk of infection, it would be important to notify the physician if the client's urine odor becomes foul, possibly suggesting a urinary tract infection. Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, p. 270

The nurse is teaching a client with schizoaffective disorders (SAD) about the client's prescribed medication therapy. The nurse determines that additional education is needed when the client states what?

"One day, I won't have to worry about taking any medication." After the client's condition has stabilized (i.e., the client exhibits a decrease in positive and negative symptoms), the treatment that led to remission of symptoms should be continued. Titrating antipsychotic agents to the lowest dose that provides suitable protection may enable optimal psychosocial functioning while slowing the recurrence of new episodes. Clients diagnosed with SAD are unlikely to be medication free. Clients also need education about preventing orthostatic hypotension, such as changing positions slowly, as well as drinking adequate amounts of fluid each day. Clients also need to notify their health care provider if they notice any abnormal muscle movement or the inability to control motor movement. Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, p. 269.

A client diagnosed with schizophreniform disorder must have symptoms present for at least 1 month but with a duration of less than:

6 months

A client diagnosed with schizophrenia has been prescribed clozapine. Which is a potentially fatal side effect of this medication?

Agranulocytosis Agranulocytosis is manifested by a failure of the bone marrow to produce adequate white blood cells. Neuroleptic malignant syndrome is a life-threatening reaction to neuroleptic medication that requires immediate treatment. Tardive dyskinesia causes involuntary movements of the tongue, mouth, facial muscles, and arm and leg muscles. Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles. Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, p. 274.

A client with schizophrenia is prescribed an antipsychotic medication. Which immediate side effects would the nurse include in the education plan for this medication?

The potential for sedation

A nurse monitoring client medication needs to recognize side effects quickly and intervene promptly for which reason?

Alleviate the side effects and help client maintain adherence Recognizing a medication's side effects quickly and intervening promptly to alleviate them will help maintain adherence. Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, p. 286.

Which statement is true about delusional disorder?

Behavior is relatively normal except when focused on the delusion. The course of delusional disorder is variable. The onset can be acute, or the disorder can occur gradually and become chronic. Clients usually live with delusions for years, rarely receiving psychiatric treatment unless their delusion relates to their health (somatic delusion) or they act on the basis of their delusion and violate laws or social rules. Apart from the direct impact of the delusion, psychosocial functioning is not markedly impaired. Behavior is remarkably normal except when the client focuses on the delusion. At that time, the client's thinking, attitudes, and mood may change abruptly. Personality does not usually change, but the client is gradually, progressively involved with the delusional concern. Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, p. 267.

The client has been diagnosed with schizophrenia and is showing the following symptoms: immobility, rigidity, and stupor. These symptoms can be further classified as which characteristic symptoms of schizophrenia?

Catatonic Catatonic clients show motoric immobility or stupor, rigidity, excessive motor activity, extreme negativism, stupor, and peculiarities of movement, such as posturing, echolalia and echopraxia, mutism, and waxy flexibility. Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, p. 267.

A client with schizophrenia is exhibiting hallucinations and delusions. The mental health nurse knows that these symptoms are associated with hyperactivity of which neurotransmitter?

Dopamine Positive symptoms of schizophrenia (specifically hallucinations and delusions) are thought to be related to dopamine hyperactivity in the mesolimbic tract at the D2 receptor site of the striatal area, where memory and emotion are regulated. Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, p. 267.

Positive symptoms of schizophrenia, specifically hallucinations and delusions, are thought to be caused by hyperactivity of which neurotransmitter?

Dopamine Positive symptoms of schizophrenia, such as delusions and hallucinations, are thought to be caused by dopamine hyperactivity in the mesolimbic tract at the D2 receptor site in the striatal area, where memory and emotion are regulated. Hyperactivity of acetylcholine, norepinephrine, and epinephrine are not associated with schizophrenia.

During a client interview, a client states that "God has sent me a special message. I'm the only one who can carry out his plan." The nurse interprets this statement as suggesting which type of delusion?

Grandiose

A client with delusional disorder tells the nurse that the client has discovered how to jump to the moon. The nurse would document this belief as what?

Grandiose delusion Clients presenting with grandiose delusions are convinced they have a great, unrecognized talent or have made an important discovery. A less common presentation is the delusion of a special relationship with a prominent person (i.e., an adviser to the president) or of actually being a prominent person (i.e., the president). The central theme of the jealous delusion is the unfaithfulness or infidelity of a spouse or lover. The central theme of somatic delusions involves bodily functions or sensations. These clients believe they have physical ailments. Erotomanic delusions are characterized by the delusional belief that the client is loved intensely by the "loved object," who is usually married, of a higher socioeconomic status, or otherwise unattainable. The client believes that the loved object's position in life would be in jeopardy if his or her true feelings were known. Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, p. 276.

A client with schizophrenia is hearing voices that tell the client to kill the self. What term is used to identify this type of false sensory perception?

Hallucination A hallucination is a sensory perception, such as hearing voices and seeing objects, that only the client experiences. A delusion is a false belief. Flight of ideas refers to a speech pattern in which the client skips from one unrelated subject to another. Ideas of reference refers to the mistaken belief that someone or something outside the client is controlling the client's ideas or behavior.

During an admission assessment, a client with schizoaffective disorder states that the client hears the voice of God in the client's head and the voice is telling the client that the client is worthless. What would the nurse document this symptom as?

Hallucination Hallucinations are sensory perceptions with a compelling sense of reality but with no actual objective basis. During auditory hallucinations (the most common form), clients may hear the voice of God or close relatives, two or more voices with a running commentary about the client's behavior, or voices that command certain acts. Delusions are false, fixed beliefs. Avolition involves the withdrawal and inability to initiate and persist in goal-directed activity. Alogia refers to the reduced fluency and productivity of thought and speech. Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, p. 265.

Which is the central focus of persecutory delusions?

Injustice that must be remedied by legal action The focus of persecutory delusions is often on some injustice that must be remedied by legal action. Clients often see satisfaction by repeatedly appealing to courts and other government agencies. The central theme of somatic delusions involves bodily functioning or sensations. The central theme of the jealous subtype is the unfaithfulness or infidelity of a spouse or lover. Clients representing with grandiose delusions are convinced they have a great, unrecognized talent or have made an important discovery. Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, p. 276.

A nursing instructor is developing an education plan for a group of students about schizophrenia and schizoaffective disorders. The instructor identifies that in addition to psychosis, what other condition must be present at the same time for a diagnosis of schizoaffective disorder?

Mood disturbance When psychosis and mood disturbance occur at the same time, a diagnosis of schizoaffective disorder is made. Substance abuse, delirium, or anxiety are not involved with the diagnosis of schizoaffective disorder. Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, p. 265.

A client with schizophrenia is receiving antipsychotic therapy. The nurse understands that which is a medical emergency should it develop in the client?

Neuroleptic malignant syndrome Although tardive dyskinesia, parkinsonism, and akathisia can occur with antipsychotic therapy, neuroleptic malignant syndrome is a life-threatening condition and medical emergency that requires immediate treatment. Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, p. 272.

A nurse provides care to a client with schizoaffective disorder during hospitalization for acute psychosis. Nursing interventions to help the client to establish trust with the health care team is best accomplished by what?

Offering reassurance in a soft, nonthreatening voice During periods of acute psychosis, offering reassurance in a soft, nonthreatening voice and avoiding confrontational stances will help the client begin to trust the staff and nursing care. Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, p. 282.

A client with delusional disorder believes that the cook at the psychiatric hospital is trying to poison the client. The nurse would record this type of delusion as what?

Persecutory The central theme of persecutory delusions is the client's belief that he or she is being conspired against, cheated on, spied on, followed, poisoned, drugged, maliciously maligned, harassed, or obstructed in pursuit of long-term goals. Erotomanic delusions are characterized by the delusional belief that the client is loved intensely by the loved object who is usually married, of a higher economic status, or otherwise unattainable. Grandiose delusions involve the belief that the person has a great, unrecognized talent or has made an important discovery or has a special relationship with a prominent person (or of actually being a prominent person). Somatic delusions involve bodily functions or sensations, with the client believing that he or she has physical ailments. Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, p. 276.

During a client interview, a client diagnosed with delusional disorder states, "I know my spouse is being unfaithful to me with a colleague from work."The nurse interprets the client's statements as suggesting which type of delusion?

Persucatory/paranoid The client's statements reflect persucatory/paranoid delusions that focus on the unfaithfulness or infidelity of a spouse or lover. Such delusions involve the belief that others are untrustworthy in some way. With referential delusions, the ideas of reference involve the client's belief that television broadcasts, music, or newspaper articles have special meaning for him or her. In the sexual delusion subtype, ideas involve the belief that the client's sexual behavior is known to others. With grandiose delusions, individuals believe that they have a great, unrecognized talent or have made an important discovery. Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, p. 276.

A client is being seen in the health clinic. The nurse observes a shuffling gait, drooling, and slowness of movement. The client is currently taking an antipsychotic for treatment of schizophrenia. The nurse knows that which side effect is occurring?

Pseudoparkinsonism Pseudoparkinsonism is exhibited by a shuffling gait, drooling, and slowness of movement. Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles. Akathisia causes restlessness, anxiety, and jitteriness. Neuroleptic malignant syndrome causes rigidity, fever, hypertension, and diaphoresis. Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, p. 270.

Which extrapyramidal side effect is noted by a client who has bradykinesia and a shuffling gait?

Pseudoparkinsonism Pseudoparkinsonism is noted by a resting tremor, rigidity, a masklike face, and a shuffling gait. Akathisia occurs when the client has motor restlessness evidenced by pacing, rocking, or shifting from foot to foot. Symptoms of acute dystonia are intermittent or fixed abnormal postures of the eyes, face, tongue, neck, trunk, and extremities. Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, p. 270.

A nurse is caring for a client diagnosed with schizophreniform disorder. The nurse demonstrates understanding of this disorder when identifying that the client is at risk for developing what?

Schizophrenia About one third of the individuals with schizophreniform disorder recover with the other two thirds developing schizophrenia. Schizophreniform disorder is not associated with the development of personality disorder, major depression, or substance abuse. Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, p. 267.

Some research has suggested that schizophreniform disorder may be an early manifestation of which other mental health condition?

Schizophrenia Some research has suggested that schizophreniform may be an early manifestation of schizophrenia. A client exhibiting an acute reactive psychosis for less than the 6 months necessary to meet the diagnostic criteria for schizophrenia is given the diagnosis of schizophreniform disorder. Symptoms lasting beyond the 6 months warrant a diagnosis of schizophrenia.

A 20-year-old son of a client who was diagnosed with schizophrenia at the age of 25 is concerned that he may also develop the disorder. Which statement regarding schizophrenia and genetics is true?

Schizophrenia has shown a strong genetic contribution. Many studies strongly suggest a genetic contribution. Relatives of people with schizophrenia have a higher incidence of the disorder than found in the general population. First-degree relatives (i.e., parents, siblings, children) of clients with schizophrenia are at greater risk for the illness than are second-degree relatives (e.g., grandparents, grandchildren, aunts, uncles, half-siblings). Schizophrenia is 13% more likely to develop in children with one parent who has schizophrenia than in those with unaffected parents; when both parents have schizophrenia, a child has a 46% risk for the illness. Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, p. 267.

A nurse is assessing a client who is reporting the sensation of "bugs crawling under the skin" and intense itching and burning. The client states, "I know bugs have invaded my body." There is no evidence to support the client's report. The nurse interprets this as which type of delusion?

Somatic Somatic delusions involve bodily functions or sensations, such as insects having infested the skin. The client vividly describes crawling, itching, burning, swarming, and jumping on the skin surface or below the skin. The client maintains the conviction that he or she is infested with parasites in the absence of objective evidence to the contrary. Nihilistic delusions focus on impending death or disaster. Clients presenting with grandiose delusions are convinced they have a great, unrecognized talent or have made an important discovery. The central theme of persecutory delusions is the client's belief that he or she is being conspired against, cheated, spied on, followed, poisoned, drugged, maliciously maligned, harassed, or obstructed in pursuit of long-term goals. Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, p. 276.

A client diagnosed with schizophrenia states to the nurse, "My intestines are being eaten by snakes." This statement represents which type of delusion?

Somatic delusion Somatic delusions are generally vague and unrealistic beliefs about the client's health or bodily functions. Persecutory delusions involve the client's belief that "others" are planning to harm the client or are spying, following, or belittling the client in some way. Grandiose delusions are characterized by the client's claim to associate with famous people or celebrities or the client's belief that he or she is famous or capable of great feats. Referential delusions or ideas of reference involve the client's belief that television broadcasts, music, or newspaper articles have special meaning for him or her. Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, p. 276.

A client is receiving antipsychotic therapy. When describing dystonic reactions to the client,the nurse would instruct the client to watch for:

Spasms of the eye muscles Dystonic reactions are also believed to result from the imbalance of dopamine and acetylcholine, with the latter dominant. This side effect, which develops rapidly and dramatically, can be very frightening for clients as their muscles tense and their body contorts. The experience often includes spasms of the eye muscles called oculogyric crisis, in which the muscles that control eye movements tense and pull the eyeball so that the client is looking toward the ceiling. Restless is otherwise called akathesia. This is considered one form of extrapyramidal symptoms but is not an acute dystonic reaction. Lip smacking and facial grimacing are characteristic of tardive dyskinesia. Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, p. 270.

A 55-year-old client was admitted to the psychiatric unit after an incident in a department store in which the client accused a sales clerk of following the client around the store and stealing the client's keys. The client was subdued by the police after destroying a window display because voices had told the client that it was evil. As the nurse approached the client, the client says, "You're all out to get me, and you're one of them. They're Rostoputians and grog babies here." This demonstrates what?

Suspiciousness and neologisms

Which assessment findings in a client who is suspected of having a delusional disorder would be suggestive of a diagnosis of schizophrenia?

The client experiences frequent and sustained hallucinations. The presence of prominent and sustained hallucinations is suggestive of schizophrenia rather than delusional disorder. Nonbizarre delusions are associated with delusional disorder, and people with either diagnosis lack insight. Response to therapy does not differentiate between the two diagnoses.

A client with a delusional disorder has been undergoing individual psychotherapy. The therapy would be deemed ultimately successful when the client meets which outcome?

The client will differentiate between reality and fantasy. The ultimate goal of all forms of treatment for clients with delusional disorders is to foster the ability to distinguish between fantasy and reality. Promoting healthy coping, anxiety awareness, and healthy relationships are therapeutic outcomes, but the priority in treatment is the delusional thinking itself. Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, pp. 278-279.

Research related to the development of schizophrenia has shown what?

The disorder is thought to arise from the interaction of a biological predisposition and environmental stressors. The likelihood of first-degree relatives (including siblings and children) developing schizophrenia has long been recognized as 10 times more likely than individuals in the general population. While this likelihood clearly suggests a strong genetic factor, the concordance for schizophrenia among monozygotic (identical) twins is 50%, suggesting that there are also environmental factors. Schizophrenia is believed to be caused by the interaction of a biologic predisposition or vulnerability and environmental stressors. Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, p. 267.

Which data support a nursing diagnosis of impaired verbal communication?

The presence of neologism, echolalia, and clanging Although the client may be indecisive, have false beliefs, and lack motivation, these do not support a diagnosis of impaired verbal communication. Invented words, repetition of words heard, and rhyming do get in the way of the ability to use or understand language in the human interaction. Fixed false beliefs and an absence of energy do not support a diagnosis of impaired verbal communication, nor do pacing and running. Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, p. 274.

Schizophrenia is most often characterized by which assessment finding?

Thought disturbances and hallucinations

Clients with delusional disorder do not normally seek help independently because of their inability to establish what?

Trust Clients with delusional or shared psychotic disorders do not normally seek help independently because of their inability to establish trust. Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, p. 278.

A client diagnosed with schizophrenia states, "I want to go home, go home, go home." This is an example of which speech pattern?

Verbigeration A verbigeration is the stereotyped repetition of words or phrases that may or may not have meaning to the listener. Clang associations are ideas that are related to one another based on sound or rhyming rather than meaning. Neologisms are words invented by the client. A word salad is a combination of jumbled words and phrases that are disconnected or incoherent and make no sense to the listener. Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, p. 274.

Which is a nonneurologic side effect of antipsychotic medications?

Weight gain Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, p. 271.

Assessment of genetic predisposition supports asking a client who is exhibiting symptoms of a delusional disorder what?

Whether any family members have been diagnosed with schizophrenia Some studies have found that delusional disorders are more common among relatives of individuals with schizophrenia than would be expected by chance; thus, asking whether any family members have been diagnosed with schizophrenia could be helpful. Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, pp. 267-268.

A nurse is caring for a client who has been receiving treatment for schizophrenia with chlorpromazine for the past year. It would be essential for the nurse to monitor the client for:

tardive dyskinesia. Tardive dyskinesia is late-appearing, abnormal involuntary movements. Therefore, it is essential that the nurse monitor the client for tardive dyskinesia at this time. Weight gain (not weight loss) and new onset of diabetes (hyperglycemia) are possible side effects of an antipsychotic. Torticollis, a dystonic reaction, would occur early in antipsychotic drug treatment. Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, p. 270.

A nurse is caring for a client who has been taking clozapine for 2 weeks. The client tells the nurse, "My throat is sore, and I feel weak." The nurse assesses the client's vital signs and finds that the client has a fever. The nurse notifies the physician, expecting an order to obtain which laboratory test?

white blood cell count Clients who are taking clozapine are at risk for developing agranulocytosis; therefore, they should have their white blood cells and granulocytes monitored while taking this medication. An immediate evaluation of blood cell status is necessary when symptoms of infection are present. Liver function studies and serum potassium and sodium concentration would not be necessary based on the assessment findings. Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Schizophrenia, p. 272.