Prepu: Topic 6: Psychotic Disorders
One evening, a client with schizophrenia leaves his room and begins marching in the hall. When approached by the nurse, the client says, "God says I'm supposed to guard the area." Which of the following responses would be best?
"I understand you hear a voice. You and I are the only ones in the hall, and I don't hear a voice." Explanation: Acknowledging that the client hears a voice validates that the client's experience is real to him, while presenting reality. Answer B is not appropriate to the client's statement. Answer C feeds into the client's statement. Answer D does not deal with the patient in a serious manner.
The nurse is working with a client with schizophrenia, disorganized type. It is time for the client to get up and eat breakfast. Which of the following statements by the nurse would be most effective in helping the client prepare for breakfast?
"It's time to put your dress on now." Explanation: The client needs clear direction, with tasks broken into small steps, to begin to participate in her own self-care.
A client diagnosed with schizophrenia has been prescribed clozapine. Which is a potentially fatal side effect of this medication?
Agranulocytosis Explanation: 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.
A client has been on Haldol for 5 years when she is admitted to the inpatient unit for a recent exacerbation of her schizophrenic symptoms. Upon assessment, she has akathisia, dystonia, a stiff gait, and rigid posture. When considering interventions for the client's symptoms, which of the following would be most appropriate?
Consult with the psychiatrist and suggest that she be placed on an anticholinergic drug. Explanation: EPSs generally are treated by reducing the dose of the medication, trying a different medication, or adding a medication that reduces or eliminates side effects. Medications that reduce or eliminate EPSs are dopamine releasers, such as amantadine (Symmetrel), or anticholinergic drugs, such as trihexyphenidyl (Artane), benztropine (Cogentin), biperiden (Akineton), procyclidine (Kemadrin), and ethopropazine (Parsidol).
A nurse is assessing a client diagnosed with schizophrenia. When documenting the findings, which would the nurse identify as a positive symptom? Select all that apply.
Delusions Hallucinations Explanation: Positive symptoms reflect an excess or distortion of normal functions, including delusions and hallucinations. Negative symptoms reflect a lessening (or complete loss) of normal functions, such as restriction or flattening in the range and intensity of emotion (diminished emotional expression); reduced fluency and productivity of thought and speech (alogia); withdrawal and inability to initiate and persist in goal-directed activity (avolition); and inability to experience pleasure (anhedonia).
The most defining characteristic of undifferentiated schizophrenia is which of the following?
Displays both positive and negative symptomology Explanation: Undifferentiated schizophrenia may exhibit both positive and negative symptoms.
Which statement made by a client would indicate that the client has delusions of grandeur?
I am a magician, and my magic powers are good when the moon is full." Explanation: The correct answer is the only statement that reflects that the client believes the client has powers, abilities, or characteristics that go beyond those of normal individuals (delusions of grandeur).
Which of the following life-threatening reactions, related to neuroleptic medication, is exhibited by rigidity, fever, hypertension, and diaphoresis?
Neuroleptic malignant syndrome Explanation: The client's signs and symptoms suggest neuroleptic malignant syndrome, a life-threatening reaction to neuroleptic medication that requires immediate treatment. Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles. Tardive dyskinesia causes involuntary movements of the tongue, mouth, facial muscles, and arm and leg muscles. Akathisia causes restlessness, anxiety, and jitteriness.
The nurse working with a client who is newly diagnosed with schizophrenia would include which in the client's education?
"Schizophrenia is an illness that involves neurotransmitters, more specifically dopamine." Explanation: Schizophrenia has been shown to be an illness in which the dopamine system is affected. It is not caused by pathology in the cerebellum nor is it curable. It is responsive to medications.
The nurse enters the room of a client with schizophrenia the day after he has been admitted to an inpatient setting and says, "I would like to spend some time talking with you." The client stares straight ahead and remains silent. The best response by the nurse would be ...
"You don't need to talk right now. I'll just sit here for a few minutes." Explanation: This response indicates acceptance of the client and shows genuine interest in him, building rapport and trust.
Which client exhibits the characteristics that are typical of the prodromal phase of schizophrenia?
A 20-year-old is experiencing a gradual decrease in the ability to concentrate, be productive, and sleep restfully. Explanation: Gradual, subtle behavioral changes appear during the prodromal phase of schizophrenia, such as tension, the inability to concentrate, insomnia, withdrawal, or cognitive deficits. No symptoms are present in the premorbid phase, and relapses occur in the progressive and chronic phases. Diagnosis of the disease marks the beginning of the onset phase.
A client is considered to have an ultrahigh risk for the development of schizophrenia when the assessment process identifies ...
A sibling who experiences visual hallucinations Explanation: Researchers have recently identified three patient groups considered to be at "ultrahigh risk" for the development of schizophrenia. One of these is a family history of psychosis, which would include a sibling who experiences visual hallucinations.
A client diagnosed with schizophrenia has been prescribed Clozapine (Clozaril). Which of the following is a potentially fatal side effect of this medication?
Agranulocytosis Explanation: 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.
The client and her care team are both pleased at the client's response to quetiapine (Seroquel), which is being used to treat her schizophrenia, paranoid type. For the first time in several years, the client has expressed insight into her delusions of persecution and is able to identify her audible hallucinations as such. Accompanying this new control of her symptoms, however, the client exhibits increasing anxiety and expresses fear for her future. These feelings are characteristic of what?
Awareness syndrome Explanation: After clinical symptoms such as hallucinations, confusion, and ideas of reference are stabilized, the client may begin to experience inner emotions such as anxiety and fear as she regains an awareness of reality. This phenomenon is known as awareness syndrome or awakening phenomenon and does not signal the repression of her symptoms, tolerance to drugs, or a new manifestation of schizophrenia.
Which speech pattern is exhibited by the client stating, "I will take a pill if I go up the hill but not if my name is Jill, I don't want to kill?"
Clang association Explanation: 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 verbigeration is the stereotyped repetition of words or phrases that may or may not have meaning to the listener. A word salad is a combination of jumbled words and phrases that are disconnected or incoherent and make no sense to the listener.
Which of the following speech patterns is exhibited by the client stating, "I will take a pill if I go up the hill but not is my name is Jill, I don't want to kill"?
Clang association Explanation: 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 verbigeration is the stereotyped repetition of words or phrases that may or may not have meaning to the listener. A word salad is a combination of jumbled words and phrases that are disconnected or incoherent and make no sense to the listener.
A nurse is assessing a client diagnosed with schizophrenia. When documenting the findings, which would the nurse identify as a positive symptom? Select all that apply.
Delusions Hallucinations Explanation: Positive symptoms reflect an excess or distortion of normal functions, including delusions and hallucinations. Negative symptoms reflect a lessening (or complete loss) of normal functions, such as restriction or flattening in the range and intensity of emotion (diminished emotional expression); reduced fluency and productivity of thought and speech (alogia); withdrawal and inability to initiate and persist in goal-directed activity (avolition); and inability to experience
A physician has diagnosed a client with schizophrenia. The nurse knows that schizophrenia is characterized by which of the following?
Disturbances in affect Explanation: The Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision, defines schizophrenia as a disturbance in multiple psychological processes that affects thought content and form, perception, affect, sense of self, volition, relationship to the external world, and psychomotor behavior. Multiple personalities occur in dissociative identity disorder.
How often must clients receiving clozapine get white blood cell counts drawn?
Every week for the first 6 months Explanation: Clients taking clozapine must have weekly white blood cell counts for the first 6 months of clozapine therapy and every 2 weeks thereafter.
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 Explanation: 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.
A client with schizophrenia is hearing voices that tell him to kill himself. The nurse understands that this client is experiencing ...
Hallucination Explanation: 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.
One evening, a client with schizophrenia leaves his room and begins marching in the hall. When approached by the nurse, the client says, "God says I'm supposed to guard the area." Which of the following responses would be best?
I understand you hear a voice. You and I are the only ones in the hall, and I don't hear a voice." Explanation: Acknowledging that the client hears a voice validates that the client's experience is real to him, while presenting reality. Answer B is not appropriate to the client's statement. Answer C feeds into the client's statement. Answer D does not deal with the patient in a serious manner.
Catatonia as seen in clients with schizophrenia is unique in the existence of which feature?
Immobility like being in a trance Explanation: Catatonia, as seen in clients with schizophrenia, is a psychologically induced immobility occasionally marked by periods of agitation or excitement; the client seems motionless as if in a trance.
A client with schizophrenia is exhibiting emotional withdrawal and poor eye contact and describing hallucinations. The mental health nurse knows that these symptoms are suggestive of which neurotransmitter imbalance?
Increased serotonin and dopamine Explanation: Lack of volition and motivation, social withdrawal, and anhedonia (inability to feel pleasure) are negative signs of schizophrenia. Hallucinations are a positive sign of the disease. Second-generation antipsychotic medications, which are antagonists of dopamine and serotonin, lessen both positive and negative symptoms; this suggests that excess dopamine and serotonin are both involved in schizophrenia. The etiology of schizophrenia is still very much under investigation, but it is hypothesized that an excess of dopamine is a factor in psychosis and that, while a certain amount of serotonin can help modulate the effects of dopamine, an excess of serotonin contributes to schizophrenia. The involvement of brain anatomy, metabolism, and neurotransmitter and neuroconnectivity are also being investigated; the exact etiology of schizophrenia is complex.
A student nurse has been assigned to provide care for an inpatient psychiatric-mental health client who has a diagnosis of schizophrenia. The student nurse is apprehensive about interacting with the client. The client's detailed explanations of the client's delusions accompanied by unpredictable movements have prompted fear in the student. How should this nursing student interpret such feelings?
It is natural to feel fear when a client exhibits unpredictable behavior, and this can cause the student to be reasonably cautious. Explanation: A student may experience fear if the client exhibits unpredictable behavior. Fear is a normal response that results in the exercise of caution. Experiencing fear is not evidence of stereotyping, and divulging fear to the client is unlikely to benefit either the student or the client. The risk of violence is a reality, though the risk differs with each client.
A client had been withdrawn in the client's room for 3 days, not eating or sleeping, prior to his admission to the inpatient unit. Upon interview, the client demonstrates difficulty answering questions, appears to have no facial expressions, and cannot follow simple instructions. This cluster of symptoms can be described as what?
Negative Symptoms Explanation: Common negative symptoms of schizophrenia include alogia, affective blunting, avolition, anhedonia, and attentional impairment
A client had been withdrawn in the client's room for 3 days, not eating or sleeping, prior to his admission to the inpatient unit. Upon interview, the client demonstrates difficulty answering questions, appears to have no facial expressions, and cannot follow simple instructions. This cluster of symptoms can be described as what?
Negative symptoms Explanation: Common negative symptoms of schizophrenia include alogia, affective blunting, avolition, anhedonia, and attentional impairment.
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 Explanation: 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.
Of all the theories suggesting the origin and risk factors for schizophrenia, the one that is based almost exclusively on circumstantial evidence that hypothesizes that the disorder is metabolic is the
Organic (Pathophysiologic) Theory Explanation: Of all the theories suggesting the origin and risk factors for schizophrenia, the one that is based almost exclusively on circumstantial evidence that hypothesizes that the disorder is metabolic is the organic, or pathophysiologic, theory. Environmental, or cultural, theory hypothesizes that a faulty reaction to the environment (being unable to respond selectively to numerous social stimuli) triggers schizophrenia. Psychological, or experiential, theory is based on the effects of psychological, not physiological stressors, triggering schizophrenia. The biochemical, or neurostructural, theory includes the dopamine hypothesis, which states that an excessive amount of the dopamine allows nerve impulses to bombard the mesolimbic pathway, disrupting normal cell communication and resulting in the development of hallucinations and delusions, symptoms of schizophrenia.
A client with a diagnosis of schizophrenia has a history of auditory and visual hallucinations. Which intervention is most likely to minimize the client's hallucinations?
Provide frequent contact and communication with the client Explanation: To prevent or minimize hallucinations, the nurse should help present and maintain reality by frequent contact and communication with the client. Limiting sleep or modifying the timing of medication administration is not likely to prevent or lessen hallucinations.
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. Which of the following side effects is occurring?
Pseudoparkinsonism Explanation: Pseudoparkinsonism is exhibited by a shuffling gait, drooling, and slowness of movement. Akathisia causes restlessness, anxiety, and jitteriness. Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles. Neuroleptic malignant syndrome causes rigidity, fever, hypertension, and diaphoresis.
What are the signs and symptoms of schizophrenia according to the Diagnostic and Statistical Manual of Mental Disorders?
Schizophrenia lasts at least 6 months and includes at least 1 month of 2 or more active-phase symptoms. Explanation: According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, (DSM-5), schizophrenia lasts at least 6 months and includes at least 1 month of 2 or more active-phase symptoms such as bizarre delusions, hallucinations (e.g., a running commentary of two voices conversing), disorganized speech, grossly disorganized or catatonic behavior, and negative behavior.
A client with a long history of schizophrenia has managed well on fluphenazine. The client reports smacking of the lips and sticking out the tongue. Based on this report, what does the nurse suspect is occurring with the client?
Signs of tardive dyskinesia (TD) associated with neuroleptic medication Explanation: TD is a type of extrapyramidal side effect characterized by abnormal, involuntary, irregular, choreoathetoid (writhing) movements, which may include lip smacking, neck twisting, facial grimacing, and tongue and chewing movements. TD can occur after several months to years of therapy with traditional antipsychotics.
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 Explanation: 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.
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 Explanation: 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.
Which of the following terms describes the use of words or phrases that are flowery, excessive, and pompous?
Stilted language Explanation: Stilted language is the use of words or phrases that are flowery, excessive, and pompous. A word salad is a combination of jumbled words and phrases that are disconnected or incoherent and make no sense to the listener. Neologisms are words invented by the client. Clang associations are ideas that are related to one another based on sound or rhyming rather than meaning.
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 Explanation: The client is demonstrating suspiciousness ("you're all out to get me") and neologisms (use of the words "Rostoputians and grog babies"). Loose associations and flight of ideas occur when the client talks about many topics in rapid sequence, but they are not connected with each other. Illusions are when the client sees something that is not there; echolalia is the repetition of words (or words that sound similar) said by someone else.
The client's diagnosis of schizoaffective disorder is supported when the nurse documents what?
The client reports "hearing voices" for the last 3 months Explanation: The client's diagnosis of schizoaffective disorder is supported when the nurse documents that the client reports "hearing voices" for the last 3 months. The documentation is objective and includes a direct quote from the actual client. What is being documented is consistent with the criteria for schizoaffective disorder.
A client diagnosed with schizophrenia states, "I want to go home, go home, go home." This is an example of which speech pattern?
Verbigeration Explanation: 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.
A client diagnosed with schizophrenia states, "I want to go home, go home, go home." This is an example of which of the following speech patterns?
Verbigeration Explanation: 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.
A client is admitted to the psychiatric hospital with a diagnosis of catatonic schizophrenia. During the physical examination, the client's arm remains outstretched after the nurse obtains the pulse and blood pressure, and the nurse must reposition the arm. This client is exhibiting
Waxy flexibility Explanation: Waxy flexibility, the ability to assume and maintain awkward or uncomfortable positions for long periods, is characteristic of catatonic schizophrenia. Clients commonly remain in these awkward positions until someone repositions them. Clients with dependency problems may demonstrate suggestibility, a response pattern in which one easily agrees to the ideas and suggestions of others rather than making independent judgments. Negativity (for example, resistance to being moved or being asked to cooperate) and retardation (slowed movement) also occur in catatonic clients.
Which of the following is a combination of jumbled words and phrases that are disconnected or incoherent and make no sense to the listener?
Word salad Explanation: A word salad is a combination of jumbled words and phrases that are disconnected or incoherent and make no sense 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. Echolalia is the client's imitation or repetition of what the nurse says.
A nurse is working with a client that has been diagnosed with delusional thoughts. Which is an initial short-term outcome appropriate for this client?
engage in reality oriented conversation Explanation: Delusions are not reality oriented; thus an appropriate outcome would be that the client will engage in reality-oriented conversation rather than discussing delusional beliefs. Delusions are fixed, false beliefs. Clients rarely accept anyone using logic to dispute them. Data are not present to suggest boundary disturbance. Explaining the delusion is not progress; it suggests the client still holds to the belief.
