MH Chapter 12: Schizophrenia Spectrum Disorders Halter: Varcarolis' Foundations of Psychiatric-M

A client diagnosed with schizophrenia begins to talk about "MacNab's" hiding in the warehouse at work. The client's use of "MacNab's" should be documented using what term? a. a neologism. b. concrete thinking. c. thought insertion. d. an idea of reference.

ANS: A A neologism is a newly coined word having special meaning to the client. "Macnab's" is not a known common word. Concrete thinking refers to the inability to think abstractly. Thought insertion refers to thoughts of others are implanted in one's mind. Ideas of reference are a type of delusion in which trivial events are given personal significance.

The family of a client diagnosed with schizophrenia is unfamiliar with the illness and family's role in recovery. Which type of therapy should the nurse recommend? a. Psychoeducational b. Psychoanalytic c. Transactional d. Family

ANS: A A psychoeducational group explores the causes of schizophrenia, the role of medication, the importance of medication compliance, support for the ill member, and hints for living with a person with schizophrenia. Such a group can be of immeasurable practical assistance to the family. the other types of therapy do not focus on psychoeducation.

A client diagnosed with schizophrenia is very disturbed and violent. After several doses of haloperidol, the client is calm. Two hours later the nurse sees the client's head rotated to one side in a stiff position, the lower jaw thrust forward, and drooling. Which problem is most likely? a. An acute dystonic reaction b. Tardive dyskinesia c. Waxy flexibility d. Akathisia

ANS: A Acute dystonic reactions involve painful contractions of the tongue, face, neck, and back. Opisthotonos and oculogyric crisis may be observed. Dystonic reactions are considered emergencies requiring immediate intervention. Tardive dyskinesia involves involuntary spasmodic muscular contractions that involve the tongue, fingers, toes, neck, trunk, or pelvis. It appears after prolonged treatment. Waxy flexibility is a symptom seen in catatonic schizophrenia. Internal and external restlessness, pacing, and fidgeting are characteristics of akathisia.

A nurse asks a client diagnosed with schizophrenia, "What is meant by the old saying 'You can't judge a book by looking at thecover.'?" Which response by the client indicates concrete thinking? a. "The table of contents tells what a book is about." b. "You can't judge a book by looking at the cover." c. "Things are not always as they first appear." d. "Why are you asking me about books?"

ANS: A Concrete thinking refers to an impaired ability to think abstractly. Concreteness is often assessed through the client's interpretation of proverbs. Concreteness reduces one's ability to understand and address abstract concepts such as love or the passage of time. the incorrect options illustrate echolalia, an unrelated question, and abstract thinking.

An acutely violent client diagnosed with schizophrenia received several doses of haloperidol. Two hours later the nurse notices the client's head rotated to one side in a stiffly fixed position, the lower jaw thrust forward, and drooling. Which intervention by the nurse is indicated? a. Administer diphenhydramine 50 mg IM from the prn medication administration record. b. Reassure theclient that thesymptoms will subside. Practice relaxation exercises with the client. c. Give trihexyphenidyl 5 mg orally at the next regularly scheduled medication administration time. d. Administer atropine sulfate 2 mg subcut from theprn medication administration record.

ANS: A Diphenhydramine, trihexyphenidyl, benztropine, and other anticholinergic medications may be used to treat dystonias. Swallowing will be difficult or impossible; therefore, oral medication is not an option. Medication should be administered immediately, so the intramuscular route is best. In this case, the best option given is diphenhydramine.

When a client diagnosed with schizophrenia was discharged 6 months ago, haloperidol was prescribed. The client now says, "I stopped taking those pills. They made me feel like a robot." What are common side effects that nurse should validate with the client? a. Sedation and muscle stiffness b. Sweating, nausea, and diarrhea c. Mild fever, sore throat, and skin rash d. Headache, watery eyes, and runny nose

ANS: A Typical antipsychotic drugs often produce sedation and extrapyramidal side effects such as stiffness and gait disturbance, effects the client might describe as making him or her feel like a "robot." The side effects mentioned in the other options are usually not associated with typical antipsychotic therapy or would not have the effect described by the client.

What assessment findings mark the prodromal stage of schizophrenia? a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion b. Auditory hallucinations, ideas of reference, thought insertion, and broadcasting c. Stereotyped behavior, echopraxia, echolalia, and waxy flexibility d. Loose associations, concrete thinking, and echolalia neologisms

ANS: A Withdrawal, misinterpreting, poor concentration, and preoccupation with religion are prodromal symptoms, the symptoms that are present before the development of florid symptoms. the incorrect options each list the positive symptoms of schizophrenia that might be apparent during the acute stage of the illness.

A newly hospitalized client experiencing psychosis says, "Red chair out town board." Which term should the nurse use to document this finding? a. Word salad b. Neologism c. Anhedonia d. Echolalia

ANS: A Word salad is a jumble of words that is meaningless to the listener and perhaps to the speaker as well, because of an extreme level of disorganization.

A client diagnosed with schizophrenia was hospitalized after arguing with co-workers and threatening to harm them. The client is aloof, suspicious, and says, "Two staff members I saw talking were plotting to kill me." Based on data gathered at this point, which nursing diagnoses relate? (Select all that apply.) a. Risk for other-directed violence b. Disturbed thought processes c. Risk for loneliness d. Spiritual distress e. Social isolation

ANS: A, B Delusions of persecution and ideas of reference support the nursing diagnosis of disturbed thought processes. Risk for other-directed violence is substantiated by the client's feeling endangered by persecutors. Fearful individuals may strike out at perceived persecutors or attempt self-harm to get away from persecutors. Data are not present to support the other diagnoses.

A nurse at the mental health clinic plans a series of psychoeducational groups for persons newly diagnosed with schizophrenia. Which two topics take priority? (Select all that apply.) a. "The importance of taking your medication correctly" b. "How to complete an application for employment" c. "How to dress when attending community events" d. "How to give and receive compliments" e. "Ways to quit smoking"

ANS: A, E Stabilization is maximized by adherence to the antipsychotic medication regimen. Because so many persons with schizophrenia smoke cigarettes, this topic relates directly to the clients' physiological well-being. The other topics are also important but are not priority topics.

A nurse observes a catatonic client standing immobile, facing the wall with one arm extended in a salute. the client remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon? a. Echolalia b. Catatonia c. Depersonalization d. Thought withdrawal

ANS: B Catatonia is the ability to hold distorted postures for extended periods of time, as though the client were molded in wax. Echolalia is a speech pattern. Depersonalization refers to a feeling state. Thought withdrawal refers to an alteration in thinking.

A client's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the client may be hallucinating? a. Detachment and overconfidence b. Darting eyes, tilted head, mumbling to self c. Euphoric mood, hyperactivity, distractibility d. Foot tapping and repeatedly writing the same phrase

ANS: B Clues to hallucinations include eyes looking around the room as though to find the speaker, tilting the head to one side as though listening intently, and grimacing, mumbling, or talking aloud as though responding conversationally to someone.

A nurse leads a psychoeducational group about first-generation antipsychotic medications with six adult men diagnosed with schizophrenia. The nurse will monitor for concerns regarding body image with respect to which potential side effect of these medications? a. Constipation b. Gynecomastia c. Visual changes d. Photosensitivity

ANS: B FGAs (first-generation antipsychotic) stimulate release of prolactin, which can result in gynecomastia (enlargement of the breasts) as well as other changes in sexual function. Men may experience disturbances in body image as a result of gynecomastia. Other side effects of FGAs may be disturbing to other aspects of the client's physical health but are not likely to bother body image.

A client diagnosed with schizophrenia has received fluphenazine decanoate twice a month for 3 years. the clinic nurse notes that the client grimaces and constantly smacks both lips. The client's neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect? a. Agranulocytosis b. Tardive dyskinesia c. Tourette's syndrome d. Anticholinergic effects

ANS: B Fluphenazine decanoate is a first-generation antipsychotic medication. Tardive dyskinesia is a condition involving theface, trunk, and limbs that occurs more frequently with first-generation antipsychotics than second or third generation. Involuntary movements, such as tongue thrusting; licking; blowing; irregular movements of the arms, neck, and shoulders; rocking; hip jerks; and pelvic thrusts, are seen. These symptoms are frequently not reversible even when the drug is discontinued. the scenario does not present evidence consistent with the other disorders mentioned. Agranulocytosis is a blood disorder. Tourette's syndrome is a condition in which tics are present. Anticholinergic effects include dry mouth, blurred vision, flushing, constipation, and dry eyes.

A client insistently states, "I can decipher codes of DNA just by looking at someone." Which problem is evident? a. Visual hallucinations b. Magical thinking c. Idea of reference d. Thought insertion

ANS: B Magical thinking is evident in the client's appraisal of his own abilities. There is no evidence of the distractors.

A client diagnosed with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive, but the client continues to have apathy, poverty of thought, and social isolation. The nurse would expect a change to which medication? a. Haloperidol b. Olanzapine c. Chlorpromazine d. Diphenhydramine

ANS: B Olanzapine is a second-generation atypical antipsychotic that targets both positive and negative symptoms of schizophrenia. Haloperidol and chlorpromazine are conventional antipsychotics that target only positive symptoms. Diphenhydramine is an antihistamine. See relationship to audience response question.

A client diagnosed with schizophrenia demonstrates little spontaneous movement and has catatonia. The client's activities of daily living are severely compromised. What will be an appropriate outcome for this client? a. demonstrates increased interest in the environment by the end of week 1. b. performs self-care activities with coaching by the end of day 3. c. gradually takes the initiative for self-care by the end of week 2. d. accepts tube feeding without objection by day 2.

ANS: B Outcomes related to self-care deficit nursing diagnoses should deal with increasing ability to perform self-care tasks independently, such as feeding, bathing, dressing, and toileting. Performing the tasks with coaching by nursing staff denotes improvement over the complete inability to perform the tasks. the incorrect options are not directly related to self-care activities, difficult to measure, and unrelated to maintenance of nutrition.

A newly admitted client diagnosed with schizophrenia is hypervigilant and constantly scans the environment. the client states, "I saw two doctors talking in the hall. They were plotting to kill me." the nurse may correctly assess this behavior using which term? a. echolalia. b. paranoia c. a delusion of infidelity. d. an auditory hallucination

ANS: B Paranoia is an irrational fear, ranging from mild (being suspicious, wary, guarded) to profound (believing irrationally that another person intends to kill you).; for example, when seeing two people talking, the individual assumes they are talking about him or her. the other terms do not correspond with the scenario.

A client has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today this client shouts, "They're all plotting to destroy me. Isn't that true?" What is the nurse's most therapeutic response? a. "Everyone here is trying to help you. No one wants to harm you." b. "Feeling that people want to destroy you must be very frightening." c. "That is not true. People here are trying to help you if you will let them." d. "Staff members are health care professionals who are qualified to help you."

ANS: B Resist focusing on content; instead, focus on the feelings the client is expressing. This strategy prevents arguing about the reality of delusional beliefs. Such arguments increase client anxiety and the tenacity with which the client holds to the delusion. The other options focus on content and provide opportunity for argument.

A client says, "Facebook has a new tracking capacity. If I use the Internet, Homeland Security will detain me as a terrorist." What is the nurse's best initial action? a. Tell the client, "Facebook is a safe website. You don't need to worry about Homeland Security." b. Tell theclient, "You are in a safe place where you will be helped." c. Administer a prn dose of an antipsychotic medication. d. Tell the client, "You don't need to worry about that."

ANS: B The client is experiencing paranoia and delusional thinking, which leads to fear. Explaining that the client is in a safe place will help relieve the fear. It is not therapeutic to disagree or give advice. Medication will not relieve the immediate concern.

A client diagnosed with schizophrenia says, "My co-workers are out to get me. I also saw two doctors plotting to kill me." How does this client perceive the environment? a. Disorganized b. Dangerous c. Supportive d. Bizarre

ANS: B The client sees the world as hostile and dangerous. This assessment is important because the nurse can be more effective by using empathy to respond to the client. Data are not present to support any of the other options.

Which hallucination expressed by a client necessitates the nurse to implement safety measures? a. "I hear angels playing harps." b. "The voices say everyone is trying to kill me." c. "My dead father tells me I am a good person." d. "The voices talk only at night when I'm trying to sleep."

ANS: B The correct response indicates the client is experiencing paranoia. Paranoia often leads to fearfulness, and the client may attempt to strike out at others to protect self. The distracters are comforting hallucinations or do not indicate paranoia.

Which finding constitutes a negative symptom associated with schizophrenia? a. Hostility b. Bizarre behavior c. Poverty of thought d. Auditory hallucinations

ANS: C Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning. The distracters are positive symptoms of schizophrenia. See relationship to audience response question.

A nurse educates a client about the antipsychotic medication regime. Afterward, which comment by the client indicates the teaching was effective? a. "I will need higher and higher doses of my medication as time goes on." b. "I need to store my medication in a cool dark place, such as the refrigerator." c. "Taking this medication regularly will reduce theseverity of my symptoms." d. "If I run out or stop taking my medication, I will experience withdrawal symptoms."

ANS: C Antipsychotic drugs provide symptom control and allow most clients diagnosed with schizophrenia to live and be treated in the community. Dosing is individually determined. Antipsychotics are not addictive; however, they should be discontinued gradually to minimize a discontinuation syndrome.

The nurse assesses a client diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia? a. Auditory hallucinations b. Delusions of grandeur c. Poor personal hygiene d. Psychomotor agitation

ANS: C Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning. the distractors are positive symptoms of schizophrenia. See relationship to audience response question.

A client diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates catatonia. Which client needs are of priority importance? a. Self-esteem b. Psychosocial c. Physiological d. Self-actualization

ANS: C Physiological needs must be met to preserve life. A client with catatonia must be fed by hand or tube, toileted, given range-of-motion exercises, and so forth to preserve physiological integrity. Cattonia may also precipitate a risk for falls; therefore, safety is a concern. Higher level needs are of lesser concern.

A client diagnosed with schizophrenia has taken fluphenazine 5 mg po bid for 3 weeks. The nurse now observes a shuffling propulsive gait, a mask-like face, and drooling. Which term applies to these symptoms? a. Neuroleptic malignant syndrome b. Hepatocellular effects c. Pseudoparkinsonism d. Akathisia

ANS: C Pseudoparkinsonism induced by antipsychotic medication mimics the symptoms of Parkinson's disease. It frequently appears within the first month of treatment and is more common with first generation antipsychotic drugs. Hepatocellular effects would produce abnormal liver test results. Neuroleptic malignant syndrome is characterized by autonomic instability. Akathisia produces motor restlessness.

A newly admitted client diagnosed with schizophrenia says, ―The voices are bothering me. They yell and tell me I am bad. I have got to get away from them.‖ Select the nurse's most helpful reply. a. "Do you hear the voices often?" b. "Do you have a plan for getting away from the voices?" c. "I'll stay with you. Focus on what we are talking about, not the voices." d. "Forget the voices and ask some other clients to play cards with you."

ANS: C Staying with a distraught client who is hearing voices serves several purposes: ongoing observation, the opportunity to provide reality orientation, a means of helping dismiss the voices, the opportunity of forestalling an action that would result in self-injury, and general support to reduce anxiety. Asking if the client hears voices is not particularly relevant at this point. Asking if the client plans to "get away from the voices" is relevant for assessment purposes but is less helpful than offering to stay with the client while encouraging a focus on their discussion. Suggesting playing cards with other clients shifts responsibility for intervention from the nurse to the client and other clients.

A client diagnosed with schizophrenia begins a new prescription for ziprasidone. The client is 5'6'' and currently weighs 204 lbs. The client has dry flaky skin, headaches about twice a month, and a family history of colon cancer. Which intervention has the highest priority for the nurse to include in the client's plan of care? a. Skin care techniques b. Scheduling a colonoscopy c. Weight management strategies d. Teaching to limit caffeine intake

ANS: C Ziprasidone is a second-generation antipsychotic medication. The incidence of weight gain, diabetes, and high cholesterol is high with second-generation antipsychotic medications. The client is overweight now, so weight management will be especially important. The other interventions may occur in time, but do not have the priority of weight management.

A health care provider considers which antipsychotic medication to prescribe for a client diagnosed with schizophrenia who has auditory hallucinations and poor social function. the client is also overweight and hypertensive. Which drug should the nurse advocate? a. Clozapine b. Ziprasidone c. Olanzapine d. Aripiprazole

ANS: D Aripiprazole is a third-generation atypical antipsychotic effective against both positive and negative symptoms of schizophrenia. It causes little or no weight gain and no increase in glucose, high- or low-density lipoprotein cholesterol, or triglycerides, making it a reasonable choice for a client with obesity or heart disease. Clozapine may produce agranulocytosis, making it a poor choice as a first-line agent. Ziprasidone may prolong theQT interval, making it a poor choice for a client with cardiac disease. Olanzapine fosters weight gain.

A nurse leads a psychoeducational group about problem solving with six adults diagnosed with schizophrenia. Which teaching strategy is likely to be most effective? a. Suggest analogies that might apply to a common daily problem. b. Assign each participant a problem to solve independently and present to the group. c. Ask each client to read aloud a short segment from a book about problem solving. d. Invite participants to come up with solution to getting incorrect change for a purchase.

ANS: D Concrete thinking, an impaired ability to think abstractly resulting in interpreting or perceiving things in a literal manner, is evident in many clients diagnosed with schizophrenia. People who think concretely benefit from concrete situations during education. Finding a solution in order to get incorrect change for a purchase is an example of a concrete situation. Analogies require abstract thinking and insight. Independently solving a problem and presenting it to the group may be intimidating. All participants may or may not be literate.

The nurse is developing a plan for psychoeducational sessions for a small group of adults diagnosed with schizophrenia. Which goal is best for this group's members? a. gain insight into unconscious factors that contribute to their illness. b. explore situations that trigger hostility and anger. c. learn to manage delusional thinking. d. demonstrate improved social skills.

ANS: D Improved social skills help clients maintain relationships with others. These relationships are important to management of the disorder. Most clients with schizophrenia think concretely, so insight development is unlikely. Not all clients with schizophrenia experience delusions.

A client diagnosed with schizophrenia anxiously tells the nurse, "The voice is telling me to do things." What is the nurse's priority assessment question? a. "How long has the voice been directing your behavior?" b. "Does what the voice tell you to do frighten you?" c. "Do you recognize the voice speaking to you?" d. "What is the voice telling you to do?"

ANS: D Learning what a command hallucination is telling the client to do is important because the command often places the client or others at risk for harm. Command hallucinations can be terrifying and may pose a psychiatric emergency. the incorrect questions are of lesser importance than identifying the command.

A client diagnosed with schizophrenia says, "It's beat. Time to eat. No room for the cat." What type of verbalization is evident? a. Neologism b. Idea of reference c. Thought broadcasting d. Associative looseness

ANS: D Looseness of association refers to jumbled thoughts incoherently expressed to the listener. Neologisms are newly coined words. Ideas of reference are a type of delusion. Thought broadcasting is the belief that others can hear one's thoughts.

A client diagnosed with schizophrenia has been stable for a year; however, the family now reports the client is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. the client says, "My computer is sending out infected radiation beams." The nurse can correctly assess this information as an indication of what? a. the need for psychoeducation. b. medication nonadherence. c. chronic deterioration. d. relapse.

ANS: D Signs of potential relapse include feeling tense, difficulty concentrating, trouble sleeping, increased withdrawal, and increased bizarre or magical thinking. Medication nonadherence may not be implicated. Relapse can occur even when the client is taking medication regularly. Psychoeducation is more effective when the client's symptoms are stable. Chronic deterioration is not the best explanation.

A client receiving risperidone reports severe muscle stiffness at 1030. By 1200, the client has difficulty swallowing and is drooling. By 1600, vital signs are 102.8° F; pulse 110; respirations 26; 150/90. theclient is diaphoretic. What is the nurse's best analysis and action? a. Agranulocytosis; institute reverses isolation. b. Tardive dyskinesia; withhold the next dose of medication. c. Cholestatic jaundice; begin a high-protein, high-cholesterol diet. d. Neuroleptic malignant syndrome; notify health care provider stat.

ANS: D Taking an antipsychotic medication coupled with the presence of extrapyramidal symptoms, such as severe muscle stiffness and difficulty swallowing, hyperpyrexia, and autonomic symptoms (pulse elevation), suggest neuroleptic malignant syndrome, a medical emergency. the symptoms given in the scenario are not consistent with the medical problems listed in the incorrect options.

A client diagnosed with schizophrenia anxiously says, "I can see the left side of my body merging with thewall, then my face appears and disappears in themirror." While listening, the nurse should engage in what behavior? a. sit close to the client. b. place an arm protectively around the client's shoulders. c. place a hand on the client's arm and exert light pressure. d. maintain a normal social interaction distance from the client.

ANS: D The client is describing phenomena that indicate personal boundary difficulties and depersonalization. The nurse should maintain appropriate social distance and not touch the client because the client is anxious about the inability to maintain ego boundaries and merging or being swallowed by the environment. Physical closeness or touch could precipitate panic.

A nurse sits with a client diagnosed with schizophrenia. The client starts to laugh uncontrollably, although the nurse has not said anything funny. What is the nurse's most therapeutic response? a. "Why are you laughing?" b. "Please share the joke with me." c. "I don't think I said anything funny." d. "You're laughing. Tell me what's happening."

ANS: D The client is likely laughing in response to inner stimuli, such as hallucinations or fantasy. Focus on the hallucinatory clue (the client's laughter) and then elicit the client's observation. The incorrect options are less useful in eliciting a response: no joke may be involved, ―why‖ questions are difficult to answer, and the client is probably not focusing on what the nurse said in the first place.

A client diagnosed with schizophrenia says, "Contagious bacteria are everywhere. When they get in your body, you will be locked up with other infected people." Which problem is evident? a. Poverty of content b. Concrete thinking c. Neologisms d. Paranoia

ANS: D The client's unrealistic fear of harm indicates paranoia. Neologisms are invented words. Concrete thinking involves literal interpretation. Poverty of content refers to an inadequate fund of information.

A client diagnosed with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It blows away. Get it?" What is the nurse's most therapeutic response? a. "Nothing you are saying is clear." b. "Your thoughts are very disconnected." c. "Try to organize your thoughts and then tell me again." d. "I am having difficulty understanding what you are saying."

ANS: D When a client's speech is loosely associated, confused, and disorganized, pretending to understand is useless. The nurse should tell the client that he or she is having difficulty understanding what the client is saying. If a theme is discernible, ask the client to talk about the theme. The incorrect options tend to place blame for the poor communication with the client. The correct response places the difficulty with the nurse rather than being accusatory.