NSG 304 Psych Module 5 Test Schizophrenia and Other Psychiatric Disorders

Positives Symptoms Hallucinations and Illusions

Auditory-False sounds Visual-False visions Tactile-False sense of touch Gustatory-False taste Olfactory-False smell

Tardive Dyskinesia

It is a possible side effect of antipsychotics. Symptoms are bizarre facial and tongue movements "tongue smack", stiff neck, and difficulty swallowing. Symptoms are irreversible and medications should be stopped at first sign New treatment is velbenzaine (Ingrezza) Fatigue and dry mouth are common side effects

Phase 4 Residual Phase

Usually follows an active phase; acute symptoms absent, negative symptoms remain Flat affect and impairment in role functioning are prominent

Negative Symptoms Psychomotor Behavior

*Anergia-*Deficiency of energy *Waxy Flexibility-*Allows body parts to be moved in uncomfortable or bizarre positions *Posturing-*Voluntary assumption of bizarre or inappropriate postures *Pacing and Rocking-*Common psychomotor behaviors

Positive Symptoms Form of Thought

*Associative looseness-*Ideas shift from one unrelated topic to another and individual is unaware topics are unrelated *Neologisms-*Person invents new words *Concrete thinking-*Regression to an earlier level of cognition-individual would not understand abstract meaning of it's raining cats and dogs *Clang association-*Words often take the form of rhyming *Word salad-*Group of words put together randomly without logical connection *Circumstantiality-*Communication with unnecessary and tedious details *Tangentiality-*Person never really gets to the point of the communication *Mutism-*Inability or refusal to speak *Perseveration-*Persistently repeats same word or idea in response to different questions

Positive Symptoms Sense of Self

*Echolalia-*Repeat words they hear *Echopraxia-*Imitate movements *Identification and Imitation-*ID-occurs on subconscious level, Imitation on conscious level; ego defense mechanism *Depersonalization-*Feelings of unreality-One's extremities have changed in size or sense of seeing oneself from a distance

Schizophrenia Predisposing Factors

*Genetics-*Increased risk, especially in monozygotic twins *Biochemical factor-*Excess dopamine in brain; abnormalities in neurotransmitters *Physiological influences-*Enlarged ventricles in brain, histological changes in brain, viral infections (babies born in Jan, & Feb. increased risk, link to flu in mothers), various physical conditions *Environmental influences-*Poverty has been linked to development; Downward drift hypothesis-poor social conditions seen as consequence rather than cause; stressful life events may be associated with exacerbation and increased relapse; link between risk for and cannabis use in adolscents

Schizophrenia Prognosis

-Return to full premorbid functioning not common Factors associated with a positive prognosis -Good premorbid functioning -Later age at onset -Female gender -Abrupt onset precipitated by a stressful event -Associated mood disturbance -Brief duration of active phase symptoms -Minimal residual symptoms -Absence of structural brain abnormalities -Normal neurological functioning -Family history of mood disorder -No family history of schizophrenia

Brief psychotic disorder

-Sudden onset of symptoms -May or may not be preceded by a severe psychological stressor -Lasts less than a month -Return to full premorbid level of functioning

A client diagnosed with schizophrenia states, "My roommate is plotting to have others kill me." Which is the appropriate nursing response? 1) "I find that hard to believe." 2) "What would make you think such a thing?" 3) "I know your roommate. He would do no such thing." 4) "I can see why you feel that way."

1) "I find that hard to believe." Feedback 1: This client is experiencing a persecutory delusion. This nursing response is an example of "voicing doubt," which expresses uncertainty as to the reality of the client's perceptions. This is an appropriate therapeutic communication technique in dealing with clients experiencing delusional thinking. Feedback 2: This response is an example of the nontherapeutic block to communication of "indicating the existence of an external source of power." This communication technique encourages the client to project blame for his or her thoughts or behaviors on others rather than accepting the responsibility personally. Feedback 3: This response is an example of the nontherapeutic block to communication of "disagreeing." This communication technique denounces the client's ideas or behaviors and implies that the nurse has the right to pass judgment on whether the client's ideas or behaviors are "good" or "bad." Feedback 4: This nontherapeutic response reinforces the client's delusion.

A withdrawn client newly diagnosed with schizophrenia is experiencing delusional thinking. Which nursing intervention is most appropriate? 1) Present objective reality. 2) Use self-disclosure. 3) Use physical touch for reassurance. 4) Explain in depth, unit rules and regulations.

1) Present objective reality. Feedback 1: When communicating with a client diagnosed with schizophrenia, the nurse should reinforce and focus on reality by talking about real events and real people. Discussions that focus on false ideas reinforce the client's delusions. Feedback 2: Self-disclosure on the part of the nurse may be appropriate when it is judged that the information may therapeutically benefit the client. Clients diagnosed with schizophrenia have difficulty distinguishing interpersonal boundaries. The nurse's self-disclosure may confuse and aggravate the client's psychosis. Feedback 3: Clients diagnosed with schizophrenia who experience delusional thinking may be extremely suspicious of others. The client may perceive touch as threatening and may respond in a defensive or aggressive manner. Feedback 4: Clients diagnosed with schizophrenia typically experience disorganized thinking. Detailed explanations may be incomprehensible and overwhelming for this client. Simple and brief instructions should be given only as necessary.

A client experiencing command hallucinations is hospitalized after jumping from a bridge. The client's parents insist that their son fell rather than jumped. Which of the following best explains the parents' response? Select all that apply. 1) The parents are in denial about the reality of their son's mental illness. 2) The parents are grieving over the loss of their expectations for their child. 3) The parents do not understand the extent or seriousness of mental illness. 4) The parents reject the idea of their son having a mental illness. 5) The parents are showing support for their son.

1) The parents are in denial about the reality of their son's mental illness. 2) The parents are grieving over the loss of their expectations for their child. 3) The parents do not understand the extent or seriousness of mental illness. 4) The parents reject the idea of their son having a mental illness. Feedback 1: By stating the jump was a fall, the parents are expressing denial and minimizing the problem. Feedback 2: The child's attempted suicide could generate a loss of hope that their child will meet parental expectations. This can occur any time a child is physically or mentally different. Feedback 3: The parents may have a knowledge deficit and truly may not understand the implications of their child's mental illness. Feedback 4: By claiming that their son fell rather than jumped from the bridge, the parents are embracing an accidental cause and rejecting the possibility of mental illness. Feedback 5: The parents are protecting themselves from the reality of mental illness. This protects them rather than supports their son.

EPS

1. Pseudoparkinsonism (tremors, bradykinesia, and rigidity) 2. Dystonia (abnormal involuntary muscle spasms involving trunk, neck, or mouth) certain types of dystonia are torticollis which are contracted neck position, oculogyric crisis (contracted position of the eyes upward) laryngeal pharyngeal constriction which is life threatening. 3. Akathisia (a feeling of restlessness complaints of restless legs, jittery feelings, and nervous energy). 4. Akinesia (muscle weakness). *These symptoms are all treated with ABC'S, Artane, Benadryl, Cogentin, and Symmetrel (EPS can occur with antipsychotics)*

A financially secure client diagnosed with schizophrenia angrily states, "I've been taking Risperdal for 5 years. I can't afford the medication so I am not taking it anymore." Which defense mechanism is this client using? 1) Regression 2) Rationalization 3) Sublimation 4) Projection

2) Rationalization Feedback 1: Regression is used when an individual responds to stress by retreating to an earlier level of development and the comfort measures associated with that level of functioning. There is nothing presented in the question that indicates the use of the defense mechanism of regression. Feedback 2: Rationalization is used when an individual attempts to justify behaviors that are not socially acceptable. The client in the question is justifying medication noncompliance by claiming imaginary financial need. Feedback 3: Sublimation is used to re-channel drives or impulses that are personally unacceptable into activities that are constructive. There is nothing presented in the question that indicates the use of the defense mechanism of sublimation. Feedback 4: The defense mechanism of projection is used to attribute feelings or impulses unacceptable to one's self to another person. There is nothing presented in the question that indicates the use of the defense mechanism of projection.

A nursing home resident taking antipsychotic medications complains to the nurse of a stiff neck and difficulty swallowing. These symptoms are indicative of which condition? 1) Dysphonia 2) Tardive dyskinesia 3) Akathisia 4) Echolalia

2) Tardive dyskinesia Feedback 1: Dysphonia is a speech disorder caused by a dysfunction of the vocal cords. There is nothing presented in the question that would indicate the client has a speech disorder. Feedback 2: Tardive dyskinesia is a syndrome of symptoms characterized by bizarre facial and tongue movements, a stiff neck, and difficulty swallowing. This condition may occur as an adverse effect of long-term therapy with antipsychotic medications. Feedback 3: Akathisia is a condition that causes restlessness and an urgent need for movement. This is a type of extrapyramidal side effect associated with some antipsychotic medications. There is nothing presented in the question that would indicate the client is exhibiting these symptoms. Feedback 4: Echolalia is the parrot-like repetition of words spoken by another. There is nothing presented in the question that would indicate the client is exhibiting this speech pattern.

A mute client diagnosed with schizophrenia displays catatonia and waxy flexibility. Which nursing intervention would assist the client in communicating with others? 1) Providing assistance with self-care needs 2) Using clear, concrete statements 3) Conveying acceptance of client's need for false beliefs 4) Attempting to decode incomprehensible communication patterns

2) Using clear, concrete statements Feedback 1: Providing assistance with self-care needs would be an appropriate nursing intervention for clients experiencing catatonia, but this does not address the client's problems with communication. Feedback 2: The use of clear, concrete statements shows the client what is expected. Because clients diagnosed with schizophrenia experience concrete thinking, explanations must be provided at the client's concrete level of comprehension. Feedback 3: Conveying acceptance of the client's need for false beliefs is an empathetic nursing intervention that may be appropriate with clients experiencing thought disorders, but this does not address the client's problems with communication. Feedback 4: Attempting to decode incomprehensible communication patterns would apply to clients diagnosed with impaired verbal communication, not mutism. When a client is mute, there are no communication patterns to decode.

A client is admitted with a diagnosis of schizoaffective disorder. Which symptoms are characteristic of this diagnosis? 1) Strong ego boundaries and abstract thinking 2) Ataxia and akinesia 3) Altered mood and thought disturbances 4) Substance use disorder and cachexia

3) Altered mood and thought disturbances Feedback 1: Individuals diagnosed with schizoaffective disorder experience characteristic schizophrenic symptoms. These symptoms include extremely weak, not strong, ego boundaries and concrete, not abstract, thinking. Feedback 2: Ataxia is defined as muscular incoordination. Akinesia is defined as muscle weakness, or a loss or partial loss of muscle movement. Individuals diagnosed with schizoaffective disorder experience characteristic symptoms of schizophrenia. Physical symptoms are not, in and of themselves, characteristic symptoms of schizophrenia. Feedback 3: The characteristic symptoms of schizoaffective disorder are a combination of alterations in mood (mania or depression) and thought. Feedback 4: Substance use disorder may coexist with the symptoms of schizoaffective disorder, but it is not necessarily characteristic of the diagnosis. Cachexia is defined as a state of ill health, malnutrition, wasting, and extreme emaciation. This physical description is not characteristic of schizoaffective disorder.

The client hears the word "match." The client replies, "A match. I like matches. They are the light of the world. God will light the world. Let your light so shine." Which communication pattern does the nurse identify? 1) Word salad 2) Clang association 3) Loose association 4) Ideas of reference

3) Loose association Feedback 1: Word salad is a group of words put together randomly without any logical connection. The situation in the question demonstrates a connection between words and phrases verbalized by the client. Feedback 2: Clang association is a grouping of words, without any logical connection, that sound alike. For example, "It is true. I am blue. They really should have glue." The situation in the question does not demonstrate a rhyming clang association. Feedback 3: Loose association is characterized by communication in which ideas shift from one unrelated topic to another. The situation in the question clearly represents this communication pattern. Feedback 4: Ideas of reference is the delusional belief that one is being talked about by others. In the situation in the question, the client does not demonstrate any delusional belief of being talked about by others.

The nurse is providing care for an emaciated client experiencing an acute phase of catatonic stupor. Which nursing intervention would take priority when meeting this client's needs? 1) Provide speech therapy for mutism. 2) Provide physical therapy for psychomotor retardation. 3) Provide nutrient-dense foods and beverages. 4) Provide a safe environment.

3) Provide nutrient-dense foods and beverages Feedback 1: The client experiencing catatonic stupor has a motiveless resistance to speak, not the inability to speak. Therefore, this client would not benefit from speech therapy. Feedback 2: The client experiencing catatonic stupor does not have an inability to move. This client is exhibiting waxy flexibility: a motiveless resistance to all instructions or attempts to increase motor activity. This client would not benefit from physical therapy. Feedback 3: Nutrition is an essential consideration for a client experiencing catatonic stupor. The emaciated client in the question is suffering from a serious diet deficiency with possible anemia. The nurse must prioritize this basic physical need. Feedback 4: Providing a safe environment is an important intervention for any client. However, according to Maslow's hierarchy of needs, this client's inadequate nutritional intake takes priority over possible environmental injury. This client's stuporous condition would also limit exposure to safety risks.

A client diagnosed with schizophrenia is experiencing disorganized thinking. Which technique should the nurse use to promote communication? 1) Giving broad openings 2) Probing 3) Verbalizing the implied 4) Using open-ended questions

3) Verbalizing the implied Feedback 1: Broad openings allow the client to take the initiative in introducing the topic. This technique would not promote communication with clients experiencing disorganized thinking. Broad openings require the client to take the lead in the communication process, which would be difficult if thoughts are fragmented. Feedback 2: Probing is defined as the persistent questioning of the client; pushing for answers to issues that the client does not wish to discuss. This technique is nontherapeutic and not appropriate for any client. Feedback 3: When working with clients who have greatly impaired communication, the nurse can use the technique of verbalizing the implied. By putting into words what the client may be experiencing, the nurse helps the client organize his or her thinking. Feedback 4: Questions are considered open-ended when they cannot be answered by one word like "yes" or "no." These types of questions need elaboration by the client. Clients experiencing disordered thought have difficulty with complex verbal exchanges. Closed-ended questions are more appropriate when communicating with clients experiencing disorganized thinking.

A client is being discharged on haloperidol (Haldol). Which teaching should the nurse include about the medication? 1) "If you forget to take your morning dose of Haldol, double the dose at bedtime." 2) "Limit your alcohol intake to no more than 3 oz. per day." 3) "When you go home, sit outside and enjoy the sunshine." 4) "Do not stop taking Haldol abruptly."

4) "Do not stop taking Haldol abruptly." Feedback 1: Additive anticholinergic effects are observed when antipsychotic medication dosages are beyond the recommended dosage range. "Doubling" dosages may cause adverse effects. If a Haldol dose is missed, the regular dosing schedule should resume at the next prescribed time, rather than having the client take an additional dose. Feedback 2: Both Haldol and alcohol depress the central nervous system and should never be used in conjunction because of this potentiation. Feedback 3: Photosensitivity is a major side effect of Haldol. The nurse must advise the client to use plenty of sunscreen and wear protective clothing when exposed to the sun. Feedback 4: The client should be taught not to stop taking Haldol abruptly after long-term use. To do so might produce withdrawal symptoms, such as nausea, vomiting, dizziness, gastritis, headache, tachycardia, insomnia, and/or tremulousness.

Phase 3 Schizophrenia

Active phase of disorder; psychotic symptoms are prominent -Delusion -Hallucinations -Impairment in work, social relations, and self care

Difference between akathisia and akinesia

Akathisia is continuous restlessness and fidgeting. Akinesia is muscular weakness.

Associated features

Anhedonia-inability to experience pleasure Regression-Retreat to earlier stage of development

A client is admitted with a diagnosis of brief psychotic disorder, with catonic features. Which symptoms are associated with the catanoic specifier? A. Strong ego boundaries and abstract thinking B. Ataxia and akinesia C. Stupor, muscle rigidity, and negativism D. Substance abuse and cachexia

C. Stupor, muscle rigidity, and negativism

Clozapine

Drowsiness, dizziness, sedation, agranulocytosis, nausea, vomiting, dry mouth, blurred vision, seizures, weight gain, orthostatic hypotension, NMS. Precautions include; a baseline WBC at start of treatment and them weekly for the first 6 months and distribution should be controlled. Teach patient to change positions slowly and not to operate heavy machinery or operate motor vehicles until effect is known Patients may present with cold/flu like symptoms. If agranulocytosis is noted, medication must be stopped

Positive symptoms Content of Thought

Delusions-False personal beliefs that are inconsistent with person's intelligence or cultural background *Delusions of persecution-*Feels threatened and believes others intend to harm them-FBI has bugged this room *Delusions of grandeur-*An exaggerated feeling of importance, power, knowledge, or identity-I am Jesus Christ *Delusion of reference-*All events within environment are referred by the psychotic person to himself or herself-Someone is trying to get a message to me through the articles in this magazine *Delusion of control or influence-*Believes certain objects or persons have control over his or her behavior-The dentist put a filling in my tooth; I now receive transmissions through the filling that control me *Somatic delusions-*False idea about the functioning of their body-I'm 70 and will be the oldest person to give birth, the doctor says I'm not pregnant, but I know I am. *Nihilstic delusion-*False idea that the self, part of self, other, or world is nonexistent-The world no longer exists, I have no heart *Paranoia-*Extreme suspiciousness of others, their actions, or perceived intentions-I won't eat this, I know its been poisoned *Magical thinking-*Believes that their thoughts or behaviors have control over specific situations or people-It snowed last night because I wished it very hard

Negative Symptoms Volition

Emotional Ambivalence-Coexistence of opposing emotions toward same object or person Deteriorated Appearance-Neglected personal grooming and self-care activities

Delusional Disorder

Existence of prominent, non-bizarre delusions *Erotomanic type-*believes that someone, usually of higher status, is in love with them *Grandiose type-*Irrational ideas regarding their own worth, talent, knowledge, or power. Believe they have a relationship or assume identity of famous person. May be of a religious nature *Jealous type-*Believe the person's sexual partner is unfaithful *Persecutory type-*Most common type; believe they are being persecuted or malevolently treated in some way; plotted against, cheated or defrauded, followed and spied on, poisoned or drugged; may exaggerate a slight rebuff *Somatic type-*Believe they have a general medical condition *mixed type-*Delusions are prominent, but no single theme is present

Negative Symptoms Interpersonal relationship or functioning

Impaired social interaction Social Isolation Lack of Insight

Negative Symptoms Affect

Inappropriate-Emotional tone is incongruent with circumstance Bland or flat-Emotional tone is very weak Apathy-Indifference or disinterest in environment

Antipsychotic agents

Indications-Schizophrenia and other psychotic disorders, bipolar mania, antiemetics, intractable hiccoughs, control of tics in Tourette's. Contraindicated-hypersensitive, severely depressed, elderly patients with dementia, QT prolongation and other heart issues Main side effects-Dry mouth, blurred vision, constipation, urinary retention, nausea, sedation, orthostatic hypotension, photosensitivity, decreased libido, gynecomastia, weight gain, priapism, tardive dyskinesia, NMS

Catatonic Features Specifier

May be associated with other psychotic disorders, such as brief psychotic disorder, schizophreniform disorder, schizophrenia, schizoaffective disorder, and substance-induced psychotic disorder Symptoms of catatonic disorder include -Stupor and muscle rigidity or excessive purposeless motor activity -Waxy flexibility, negativism, echolalia, echopraxia

Schizophreniform Disorder

Same symptoms as schizophrenia with the exception that the duration of disorder has been at least 1 month but less than 6 months

Schizoaffective disorder

Schizophrenic symptoms accompanied by a strong element of symptomatology associated with the mood disorders either mania or depression

Neuroleptic Malignant Syndrome

Side effects-Elevated creatinine phosphokinase (CPK), fever, diaphoresis, muscle rigidity, unstable blood pressure. It is a side effect of antipsychotics (Chlorpromazine, Fluphenazine, Haloperidol, loxapine, perphenazine, thioridazine, thiothixene, trifluoperazine). It is usually treated with a skeletal muscle relaxant and a dopamine agonist like pariodel.

Phase 1 Premorbid Phase

Signs that occur before there is clear evidence of illness can include distinctive personality traits or behaviors -Social maladjustment -Antagonistic thoughts and behaviors -Shy and withdrawn -Poor peer relationships -Doing poorly in school -Antisocial behavior

Phase 2 Prodromal phase

Symptoms of the developing illness are more clearly manifested than in phase 1 -Lasts from a few weeks to a few years -Deterioration in role functioning and social withdrwal -Substantial functional impairment -Sleep disturbance, anxiety, irritability -Depressed mood, poor concentration, fatigue -Perceptional abnormalities, ideas of reference, and suspiciousness herald onset of psychosis

Antipsychotic Meds

Typical or conventional antipsychotics work by blocking the D2 receptors in the brain leading to the altered release and turnover of dopamine. Examples include; chlorpromazine, fluphenazine, haloperidol, loxapine, perphenazine, thioridazine, thiothixene, and trifluoperazine. Atypical antipsychotics work by blocking both the dopamine and serotonin receptors and have more impact on the negative symptoms of schizophrenia. These include; aripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone. Reduced EPS, increased effectiveness of treating negative and cognitive symptoms, lesser risk of tardive dyskinesia, and absence of prolactin level elevations and side effects related to it are all advantages of atypical over traditional antipsychotics