Mental Health Unit 6 (Ch. 12 & 23)
A patient's family member brings in a list of medications the patient is taking for Alzheimer disease. The patient has begun experiencing psychotic symptoms as well as dementia. Medication from which class will likely be discontinued? 1. Antipsychotics 2. Anticonvulsants 3. Antidepressants 4. Antianxiety agents
1. Antipsychotics When administered to patients with dementia, antipsychotics can cause psychotic side effects. Antidepressants, antianxiety agents, and anticonvulsants can be used in various combinations without causing psychotic symptoms.
Which question should be asked when considering the evaluation of outcomes for a patient experiencing cognitive dysfunction? Select all that apply. 1. Are the stated outcomes measureable? 2. Are the patient's cognitive skills deteriorating? 3. Is the patient capable of achieving the outcomes? 4. Are the caregivers capable of creating outcomes? 5. When were the patient's outcomes last evaluated?
1. Are the stated outcomes measureable? 2. Are the patient's cognitive skills deteriorating? 3. Is the patient capable of achieving the outcomes? 5. When were the patient's outcomes last evaluated?
Which practice demonstrates a proactive approach to minimizing the stress commonly experienced by nursing staff caring for the cognitively impaired patient? Select all that apply. 1. Realistic patient outcomes 2. Mandatory transfers off of units 3. Small nurse-to-patient care ratios 4. Thorough understanding of the disorder 5. Reasonable expectations of patient abilities
1. Realistic patient outcomes 4. Thorough understanding of the disorder 5. Reasonable expectations of patient abilities Because stress is a common occurrence when working with persons with cognitive impairments, nurses need to be proactive in minimizing its effects, which can be facilitated by having an understanding of the disease and realistic expectations. Small nurse-to-patient care ratios and mandatory transfers off of units are not realistic and are unnecessary when staff is informed and well supported in their caregiving.
A 75-year-old patient is hospitalized with sudden onset confusion and disorientation. The patient wanders and becomes agitated without any apparent stimulus. What is the highest priority nursing diagnosis? 1. Risk for injury 2. Acute confusion 3. Impaired memory 4. Self-care deficit, bathing, or hygiene
1. Risk for injury Risk for injury; acute confusion; impaired memory; and self-care deficit, bathing, or hygiene are diagnoses likely to apply in this situation; however, safety is the nurse's highest priority.
A patient diagnosed with delirium strikes out physically at a staff member. What is the most likely cause of this behavior? 1. State of fear 2. Physical illness 3. An unmet physical need 4. The need for social interaction
1. State of fear Patients with delirium often misinterpret reality, perceiving threat where none actually exists. Delirious patients who are fearful may strike out at others, seemingly without provocation. Physical illness, an unmet physical need, or the need for social interaction generally are not associated with such aggressive behavior.
Which medication is aimed at preventing the breakdown of acetylcholine? Select all that apply. 1. Tacrine 2. Donepezil 3. Rivastigmine 4. Memantine 5. Galantamine
1. Tacrine 2. Donepezil 3. Rivastigmine 5. Galantamine Because a deficiency of acetylcholine has been linked to Alzheimer's disease, medications aimed at preventing its breakdown (cholinesterase inhibitors) have been developed, including tacrine hydrochloride, donepezil, rivastigmine, and galantamine. Memantine normalizes levels of glutamate, a neurotransmitter that may contribute to neurodegeneration.
Which behavior is associated with typical age-related cognitive changes? Select all that apply. 1. Taking 30 minutes to find one's misplaced car keys. 2. Having the electricity turned off for lack of payment. 3. Experiencing difficulty recalling a synonym for happy. 4. Forgetting the address of the first apartment you rented. 5. Failing to pay the credit card bill while away on vacation.
1. Taking 30 minutes to find one's misplaced car keys. 3. Experiencing difficulty recalling a synonym for happy. 4. Forgetting the address of the first apartment you rented. 5. Failing to pay the credit card bill while away on vacation. Typical age-related cognitive changes include occasional examples of memory lapse, poor judgment, and omissions. The more serious, atypical changes involve complete, constant, or chronic issues with memory and cognition.
A nurse was assigned to select patients with Alzheimer's disease for a clinical trial of a new drug from a geriatric population. Based on what appropriate symptoms does the nurse select the patients? Select all that apply. 1. The patient has difficulty in conversing with others. 2. The patient has poor judgment and decision-making. 3. The patient reports forgetting to pay the electric bills. 4. The patient reports frequently losing things and tracing them later. 5. The patient sometimes forgets which word to use during a conversation.
1. The patient has difficulty in conversing with others. 2. The patient has poor judgment and decision-making. Geriatric patients normally have minor age-related deflects in memory. The nurse should be able to differentiate between the normal age-related changes and signs of Alzheimer's disease. Patients with Alzheimer's disease have difficulty in conversation and poor judgment and decision making. Other symptoms include inability to manage a budget, losing track of the date or the season, misplacing things and being unable to trace them. Normal age-related changes include forgetting which word to use and losing things frequently. Missing monthly payments and making a bad decision once in a while is a normal behavior and does not indicate Alzheimer's disease.
A patient with Parkinson's disease reports that bugs are crawling on his bed. The nurse checks the bed and finds peanuts on the bed. What does the nurse conclude from the patient's behavior? 1. The patient has impaired environmental interpretation syndrome. 2. The patient has delusions. 3. The patient has developed an allergy to peanuts. 4. The patient has a skin disorder.
1. The patient has impaired environmental interpretation syndrome. Patients with Parkinson's disease have confusion and dementia, and have impaired environmental interpretation syndrome. It is characterized by hallucinations and illusions. The patients tend to mistake benign objects for objects which are sinister and frightening. The patients may have tactile hallucinations, but not suffer from delusions. An allergy to peanuts or developing a skin disorder are unlikely causes of the patient's complaint, as these disorders are accompanied by other symptoms as well.
A Chinese-American patient has been diagnosed with dementia. What should the nurse keep in mind when addressing the needs of the family caregivers? Select all that apply. 1. They do not seek help from others. 2. They believe dementia is due to fate. 3. They associate dementia with stigma. 4. They perceive caregiving as burdensome. 5. They feel obligated to sacrifice individual needs. 6. They believe memory loss in early dementia is not a mental disease.
1. They do not seek help from others. 2. They believe dementia is due to fate. 3. They associate dementia with stigma. 5. They feel obligated to sacrifice individual needs. 6. They believe memory loss in early dementia is not a mental disease. Chinese-Americans depict dementia as fate or wrongdoing rather than a disease. They are less likely to seek help from others. Filial piety and family harmony are important, which emphasizes honor and devotion to parents. They feel obligated to sacrifice individual needs and wants. As the disease progresses, dementia is viewed as a mental illness with associated stigma and resulting in feelings of humiliation. Chinese-Americans do not perceive their caregiving role as burdensome. They believe that memory loss in early dementia is a part of the normal aging process. It is not viewed as a mental illness.
A female patient is brought to the hospital by her daughter, who visited the patient this morning and found her to be confused and disoriented. When the patient is admitted, the daughter states, "I'll take her glasses and hearing aid home, so they don't get lost." What would be the best response from the nurse? 1. "That will be fine. I'll have you sign our hospital release form." 2. "I would like to have your mother wear them. It will help her to be less confused." 3. "Don't worry. You can leave them at her bedside. We are insured for losses of this sort." 4. "Because we do not have a copy of durable power of attorney, we cannot release them to you."
2. "I would like to have your mother wear them. It will help her to be less confused." Patients with cognitive disorders usually profit from being able to see and hear clearly. Confusion is reduced through the use of glasses and hearing aids.
A patient diagnosed with Alzheimer's disease picks up his or her glasses from the bedside table but does not recognize what they are or their purpose. The nurse will document this behavior using which term? 1. Apraxia 2. Agnosia 3 Aphasia 4 Agraphia
2. Agnosia Agnosia is the loss of the sensory ability to recognize objects. Apraxia is the loss of purposeful movement in the absence of motor or sensory impairment. Aphasia is the loss of language ability. Agraphia is the loss of the ability to read or write.
Which nursing intervention would be most appropriate for an older individual suspected of being at risk for the development of the unique symptoms of delirium? 1. Assuring that the individual is ambulated sufficiently. 2. Assessing orientation to person, place, and time every two hours. 3. Cutting the individual's food into small pieces to avoid the risk of choking. 4. Assuring that the individual is dressed warmly to avoid the risk of hypothermia.
2. Assessing orientation to person, place, and time every two hours. Delirium reduces awareness of the environment that involves sensory misperceptions and disordered thought (disturbed attention, memory, thinking, and orientation) and also disturbances of psychomotor activity and the sleep-wake cycle. These disturbances develop rapidly (over hours to days). Frequent assessment of an individual at risk for developing delirium for orientation would be most appropriate. Assuring ambulation, cutting food into small pieces, and assuring warm clothing are appropriate but not needs unique to an individual at risk for developing delirium.
The family caregivers of an elderly Alzheimer's disease patient are feeling overburdened and overwhelmed by the situation and wish to admit the patient to an assisted care facility. What could be the primary reason? 1. Family discord 2.Caregiver role strain 3 Disruption of social life 4 Distress, guilt, rejection
2. Caregiver role strain Many families take care of the patient with Alzheimer's disease until death. Others, however, find that they can no longer cope with aggressive behavior, incontinence, wandering, unsafe behaviors, or disruptive nocturnal activity. This is known as caregiver role strain. In such cases, the caregivers may admit the patient to an assisted care facility. Disruption of social life, distress, guilt, rejection, and family discord can all be burdens on the family but are not the primary reasons in this case.
An elderly patient is diagnosed with Alzheimer's disease. What characteristic features may be seen in this patient? Select all that apply. 1.Speaks rapidly, inappropriately, and incoherently 2. Forgets familiar words or the location of everyday objects 3 . Becomes moody or withdrawn, especially in challenging situations 4. Shows altered awareness and is unable to focus, or sustain attention 5. Has increasing and frequent trouble controlling bladder and bowels
2. Forgets familiar words or the location of everyday objects 3. Becomes moody or withdrawn, especially in challenging situations 5. Has increasing and frequent trouble controlling bladder and bowels Alzheimer's disease is characterized by progressive deterioration of cognitive functioning, including forgetting familiar words or the location of everyday objects. The patient becomes moody or withdrawn, especially in socially or mentally challenging situations. The patient also has increasing and frequent trouble controlling their bladder and bowels. Delirium is an acute cognitive disturbance where the patient's speech is rapid, inappropriate, incoherent, and rambling. There is an alteration in consciousness levels. This manifests as altered awareness and inability to focus, sustain, and shift attention.
A patient's family expresses concern that the patient is developing Alzheimer disease. The patient is now 65 and was once a professional wrestler. How might this history affect the diagnosis? 1. This history will not affect the diagnosis. 2. History of head trauma is a risk factor for dementia. 3. The patient is too young to have Alzheimer disease. 4. As an athlete, the patient is less likely to have Alzheimer disease.
2. History of head trauma is a risk factor for dementia. If the patient was a professional athlete in a contact sport, there may be a history of head injury, which will affect the diagnosis. The patient's history can indeed affect the diagnosis. Although most patients who are diagnosed with Alzheimer disease are 75 or older, it is not impossible for younger patients to show signs of the disease. Other than the risk of head trauma, athletes are no more or less likely to develop the disease.
Which is a drawback of early cholinesterase inhibitors? 1. Constipation 2. Liver toxicity 3. Only useful in mild dementia 4. Increased acetylcholine levels
2. Liver toxicity Earlier forms of cholinesterase inhibitors, such as tacrine, caused liver toxicity, causing them to be withdrawn from the US market in 2012. Increasing availability of acetylcholine is a benefit for patients with dementia. These drugs are not beneficial for people with mild dementia. The side effects include nausea, vomiting, and diarrhea, not constipation.
An elderly patient, who had been healthy and living independently, was hospitalized with heart failure. The patient was treated with diuretics and antihypertensive medications. On the third hospital day, the patient became very irritable and said, "Little yellow bugs are crawling across my sheets." What is the best analysis of this scenario? 1. the pt has delusions secondary to depression 2. the pt is experiencing illusions secondary to delirium 3. Early dementia emerged because of the stress of the physical illness 4. doses of antihypertensive drugs have not managed the patients BP
2. The patient is experiencing illusions secondary to delirium Delirium is the most common complication of hospitalizations in the older adults. Illusions (errors in perception of sensory stimuli) indicate this patient is confused. Illusions, irritability, and restlessness are common in delirium. The scenario doesn't suggest the pt has dementia or depression. The pt is likely experiencing toxicity associated with the multiple medications, which is a common cause of delirium.
An elderly patient is hospitalized with pneumonia and treated with multiple antibiotics. After two days, the patient becomes irritable and restless, and says to the nurse, "My pet parakeet flew across the room." A family member says the patient has been healthy and living independently but does not own a pet. What is the most likely analysis of this scenario? 1. The patient is delusional and likely experiencing depression. 2. The patient is experiencing illusions secondary to delirium. 3. The antibiotic doses have been inadequate to treat the infection. 4. Dementia has emerged as the result of the stress of the physical illness.
2. The patient is experiencing illusions secondary to delirium. The onset of the change in mental status is acute, which is characteristic of delirium. The vision of a bird flying in the room is likely an illusion, another common characteristic of delirium. The patient's condition could be the result of the medical illness, toxicity of the drug regimen, overstimulation from the hospital environment, alcohol withdrawal, or other reasons
A patient with cognitive impairment is diagnosed with aphasia. Which symptom is the nurse most likely to find in the patient? 1. The patient wears socks on the hands. 2. The patient talks rapidly and foolishly. 3. The patient doesn't answer the nurse. 4. The patient doesn't identify sounds.
2. The patient talks rapidly and foolishly. Patients with impaired cognition show symptoms like aphasia, apraxia, preservation, and agnosia. The patient with aphasia has reduced language ability, seen as inability to use the correct word and talking rapidly and foolishly. Loss of purposeful movement is called apraxia. The person is unable to put on clothes and may wear socks on hands. The patient with preservation avoids answering the question to maintain self-esteem. Inability to identify sounds, objects, and people is known as agnosia.
A nurse communicates with a diabetic patient during their regular check-up. The nurse finds that the patient is showing symptoms of Alzheimer's disease. Which response by the patient supports the nurse's diagnosis? 1. "I missed my walk last week." 2. "I regularly go for a walk, you can ask my daughter." 3. "I regularly meet Mr. Abraham Lincoln during my walk." 4. "I don't go for a walk, because it is very cold in the morning."
3. "I regularly meet Mr. Abraham Lincoln during my walk." Patients with Alzheimer's have progressive deterioration of memory. They forget to take medication and perform important self-care activities. They tend to hide the truth by creating stories like they go for a walk with Abraham Lincoln. This behavior is called confabulation. It is not the same as lying because patients do it unconsciously to maintain self-esteem. The statement that the patient is going for a regular walk which can be confirmed with the daughter indicates confidence. The statement that the patient missed the walk indicates that the patient remembers the period and also accepts the mistake. The statement that the patient doesn't go for a walk because of cold weather indicates that the patient accepts the mistake without any guilt.
A patient is brought to the emergency room after falling in the street a mile from home. There are no serious injuries. The patient's medical record states the patient has Alzheimer disease, and the patient asks the nurse call his or her spouse, who is long deceased. What should be the focus of care? 1. Family therapy for the patient's family members 2. Health promotion, instructing the patient on ways to be safe 3. Evaluation of the home situation for safety and level of care 4. Biological reasons for the ER visit and possible psychiatric care
3. Evaluation of the home situation for safety and level of care Because patients with Alzheimer disease are at risk for wandering and getting lost, this patient's living situation should be assessed for security; he or she may require full-time care. Because the patient has no serious injuries, biological needs have already been addressed. Telling the patient how to be safe will not be effective due to the nature of the disorder. Family therapy may be helpful, but this is not the priority goal.
The nurse is assessing a patient suspected of Alzheimer's disease (AD). What action by the patient does the nurse identify as a sign of agnosia? 1. Babbles and speaks incoherently when asked any question 2. Has problem in recalling what was served for breakfast an hour ago 3. Has problem in identifying familiar sounds like the ring of the telephone 4. Talks about how he or she convinced the President to pass a particular law
3. Has problem in identifying familiar sounds like the ring of the telephone When the patient is unable to identify the ring of the telephone, it means there is a loss of sensory ability to recognize familiar sounds. The nurse recognizes it as a feature of auditory agnosia. If the patient babbles and speaks incoherently, it means there is a loss of language ability. The nurse identifies this as a sign of aphasia. In AD, there is a gradual deterioration of recent and remote memory. If the patient is unable to recall what was served for breakfast an hour ago, it indicates impairment of recent memory. Patients with AD often confabulate in an unconscious attempt to maintain self-esteem. When the patient talks about how the President's decision was influenced by the patient, the nurse should recognize it as confabulation.
Which risk factor for delirium is a direct result of external factors? 1. Fractures 2. Older age 3. Polypharmacy 4. Multiple comorbidities
3. Polypharmacy Delirium may occur as a result of polypharmacy, which can occur from a lack of continuity of care and communication, external factors. Older age and multiple conditions are internal factors. Fractures may be a result of an external cause but could also be a result of internal osteoporotic changes.
Every evening, several residents on the Alzheimer disease wing of a long-term care facility become excessively agitated. What is the term for this phenomenon? 1. Apraxia 2. Agraphia 3. Sundowning 4. Confabulation
3. Sundowning Sundowning is the term for the increase in agitation and decrease in mood in the later part of the day or night common among patients with Alzheimer disease. Confabulation describes the creation of vivid stories instead of actual memories. Agraphia refers to diminishment of reading and writing abilities. Apraxia is the loss of purposeful movement.
The term "perceptual disturbance" refers to difficulty accomplishing what task? 1. Formulating words appropriately. 2. Performing purposeful motor movements. 3. Changing one's way of thinking to accommodate new information. 4. The processing of information about one's internal and external environment.
4. The processing of information about one's internal and external environment. Perceptual disturbance refers to an impaired ability to process intellectual, sensory, and emotional data in a logical, meaningful way. Changing one's way of thinking to accommodate new information, performing purposeful motor movements, and formulating words appropriately fail to adequately describe the term perceptual disturbance.
Which statement by a person with paranoid schizophrenia most clearly indicates that the antipsychotic medication is effective? A. "I used to hear scary voices but now I don't hear them anymore." B. "My medicine is working fine. I'm not having any problems." C. "Sometimes it's hard for me to fall asleep, but I usually sleep all night." D. "I think some of the staff members don't like me. They're mean to me.
A Auditory hallucinations are a common manifestation of paranoid schizophrenia, so their absence is an indicator of medication effectiveness. "My medicine is working fine. I'm not having any problems" and "Sometimes it's hard for me to fall asleep, but I usually sleep all night" are too vague. "I think some of the staff members don't like me. They're mean to me" indicates paranoid thinking.
The causation of schizophrenia currently is understood to be A. A combination of inherited and non-genetic factors B. Deficient amounts of the neurotransmitter dopamine C. Excessive amounts of the neurotransmitter serotonin D. Stress related and ineffective stress management skills
A Causation is a complicated matter. Schizophrenia most likely occurs as a result of a combination of inherited genetic factors and extreme non-genetic factors (e.g., viral infection, birth injuries, nutritional factors) that can affect the genes governing the brain or directly injure the brain.
A nurse is educating a patient's family about schizophrenia. What is the most appropriate advice the nurse can give to the patient's family? Select all that apply. A. The nurse should advise them to keep in touch with support groups. B. The nurse should avoid mentioning the side effects of the drugs prescribed. C. The nurse should advise them to keep the patient in an isolated room. D. The nurse should advise them to adhere to the treatment plan. E. The nurse should advise them to immediately stop the medication if the patient's symptoms are relieved.
A, D The nurse should advise the family of the patient to join support groups such as National Alliance on Mental Illness and other local support groups. These groups would help to provide optimal patient care as well as support to the family. Adherence to the treatment plan would result in positive outcomes for the patient. The patient's family must be educated about the possible side effects of the prescribed drugs. This would help in effective monitoring and reducing panic in the patient and family members. The patient should be encouraged to interact with others. Keeping the patient isolated can make the patient either aggressive or withdrawn. The medications should not be stopped immediately after the symptoms are relieved as it could cause relapse of the schizophrenic symptoms. Gradually decreasing the dosage of the drug would be useful to prevent a relapse.
A nurse works with a patient in the acute phase of schizophrenia. Which assessment findings increase the risk of aggression and violence? Select all that apply. A. Paranoia B. Flat affect C. Poor hygiene D. Delusional thinking E. Command hallucinations
A, D, E A small percentage of patients with schizophrenia, especially during the acute phase, may exhibit a risk for physical violence, typically in response to hallucinations (especially command hallucinations), delusions, paranoia, and impaired judgment or impulse control. Poor hygiene and a flat affect are negative symptoms that usually are not associated with aggression or violence.
29. A patient diagnosed with schizophrenia begins to talks about "macnabs" hiding in the warehouse at work. The term "macnabs" should be documented as: 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 patient. "Macnabs" 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. REF: Page 205-206 TOP: Nursing Process: Assessment
27. The family of a patient 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. REF: Page 214 (Box 12-5) | Page 221 TOP: Nursing Process: Implementation
17. A patient diagnosed with schizophrenia is very disturbed and violent. After several doses of haloperidol (Haldol), the patient is calm. Two hours later the nurse sees the patient'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 c. Waxy flexibility b. Tardive dyskinesia 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. REF: Page 215-216 (Table 12-4) TOP: Nursing Process: Assessment
33. A nurse asks a patient diagnosed with schizophrenia, "What is meant by the old saying 'You can't judge a book by looking at the cover.'?" Which response by the patient 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 patient'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. REF: Page 205-206 TOP: Nursing Process: Assessment
18. An acutely violent patient diagnosed with schizophrenia receives several doses of haloperidol (Haldol). Two hours later the nurse notices the patient'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 (Benadryl) 50 mg IM from the PRN medication administration record. b. Reassure the patient that the symptoms will subside. Practice relaxation exercises with the patient. c. Give trihexyphenidyl (Artane) 5 mg orally at the next regularly scheduled medication administration time. d. Administer atropine sulfate 2 mg subcut from the PRN 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. REF: Page 215-216 (Table 12-4) TOP: Nursing Process: Implementatio
3. A community mental health nurse wants to establish a relationship with a very withdrawn patient diagnosed with schizophrenia. The patient lives at home with a supportive family. Select the nurse's best plan. a. Visit daily for 4 days, then every other day for 1 week stay with patient for 20 minutes, accept silence state when the nurse will return. b. Arrange to spend 1 hour each day with the patient focus on asking questions about what the patient is thinking or experiencing avoid silences. c. Visit twice daily sit beside the patient with a hand on the patient's arm leave if the patient does not respond within 10 minutes. d. Visit every other day remind the patient of the nurse's identity encourage the patient to talk while the nurse works on reports.
ANS: A Severe constraints on the community mental health nurse's time will probably not allow more time than what is mentioned in the correct option yet, important principles can be used. A severely withdrawn patient should be met "at the patient's own level," with silence accepted. Short periods of contact are helpful to minimize both the patient's and the nurse's anxiety. Predictability in returning as stated will help build trust. An hour may be too long to sustain a home visit with a withdrawn patient, especially if the nurse persists in leveling a barrage of questions at the patient. Twice-daily visits are probably not possible, and leaving after 10 minutes would be premature. Touch may be threatening. Working on reports suggests the nurse is not interested in the patient. REF: Page 210-211 | Page 215 (Box 12-6) | Page 222 (Case study and Nursing Care Plan 12-1)
12. A patient is experiencing delusions of persecution about being poisoned. The patient has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the patient? a. Allowing the patient supervised access to food vending machines b. Allowing the patient to phone a local restaurant to deliver meals c. Offering to taste each portion on the tray for the patient d. Providing tube feedings or total parenteral nutrition
ANS: A The patient who is delusional about food being poisoned is likely to believe restaurant food might still be poisoned and to say that the staff member tasting the food has taken an antidote to the poison before tasting. Attempts to tube feed or give nutrition intravenously are seen as aggressive and usually promote violence. Patients perceive foods in sealed containers, packages, or natural shells as being safer. REF: Page 205-206 (Table 12-1) TOP: Nursing Process: Planning
4. When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol (Haldol) was prescribed. The patient now says, "I stopped taking those pills. They made me feel like a robot." What are common side effects the nurse should validate with the patient? 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 patient 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 patient. REF: Page 215-216 (Table 12-4) TOP: Nursing Process: Assessment
22. 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. REF: Page 201-202 | Page 204-205 TOP: Nursing Process: Assessment
38. A newly hospitalized patient 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 (schizophasia) 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. REF: Page 205-206 TOP: Nursing Process: Assessment
2. A patient diagnosed with schizophrenia was hospitalized after arguing with co-workers and threatening to harm them. The patient 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 patient'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. REF: Page 209-210 (Table 12-3) TOP: Nursing Process: Diagnosis/Analysis
2. A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The patient states, "I saw two doctors talking in the hall. They were plotting to kill me." The nurse may correctly assess this behavior as: a. echolalia. c. a delusion of infidelity. b. an idea of reference. d. an auditory hallucination.
ANS: B Ideas of reference are misinterpretations of the verbalizations or actions of others that give special personal meanings to these behaviors 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.
24. A patient diagnosed with schizophrenia begins a new prescription for lurasidone HCL (Latuda). The patient is 5'6" and currently weighs 204 lbs. Which topic is most important for the nurse to include in the teaching plan related to this medication? a. How to recognize tardive dyskinesia b. Weight management strategies c. Ways to manage constipation d. Sleep hygiene measures
ANS: B Lurasidone HCL (Latuda) is a second-generation antipsychotic medication. The incidence of weight gain, diabetes, and high cholesterol is high with this medication. The patient is overweight now, so weight management will be especially important. The incidence of tardive dyskinesia is low with second-generation antipsychotic medications. Constipation may occur, but it is less important than weight management. This drug usually produces drowsiness. REF: Page 218-219 (Table 12-5) TOP: Nursing Process: Planning
37. A patient 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 patient's appraisal of his own abilities. There is no evidence of the distracters. REF: Page 205-206 TOP: Nursing Process: Assessment
26. A patient diagnosed with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive, but the patient continues to have apathy, poverty of thought, and social isolation. The nurse would expect a change to which medication? a. Haloperidol (Haldol) b. Olanzapine (Zyprexa) c. Chlorpromazine (Thorazine) d. Diphenhydramine (Benadryl)
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. REF: Page 219 TOP: Nursing Process: Planning
Chapter 12: Schizophrenia and Schizophrenia Spectrum Disorders 1. A person has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today the person shouts, "They're all plotting to destroy me. Isn't that true?" Select 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 patient is expressing. This strategy prevents arguing about the reality of delusional beliefs. Such arguments increase patient anxiety and the tenacity with which the patient holds to the delusion. The other options focus on content and provide opportunity for argument.
19. A patient took trifluoperazine 30 mg po daily for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patient's neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect? a. Agranulocytosis c. Tourette's syndrome b. Tardive dyskinesia d. Anticholinergic effects
ANS: B Tardive dyskinesia is a neuroleptic-induced condition involving the face, trunk, and limbs. 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. REF: Page 215-216 (Table 12-4) TOP: Nursing Process: Evaluation
5. Which hallucination necessitates the nurse to implement safety measures? The patient says, 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 patient is experiencing paranoia. Paranoia often leads to fearfulness, and the patient may attempt to strike out at others to protect self. The distracters are comforting hallucinations or do not indicate paranoia. REF: Page 207 | Page 212-213 TOP: Nursing Process: Planning
35. A client says, "Facebook has a new tracking capacity. If I use the Internet, Homeland Security will detain me as a terrorist." Select 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 the client, "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 patient is experiencing paranoia and delusional thinking, which leads to fear. Explaining that the patient 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. REF: Page 205-206 (Table 12-1) | Page 213-215 (Box 12-4)
3. A patient diagnosed with schizophrenia says, "My co-workers are out to get me. I also saw two doctors plotting to kill me." How does this patient perceive the environment? a. Disorganized c. Supportive b. Dangerous d. Bizarre
ANS: B The patient 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 patient. Data are not present to support any of the other options. REF: Page 210 (Table 12-3) | Page 213 (Box 12-4)
11. A nurse observes a catatonic patient standing immobile, facing the wall with one arm extended in a salute. The patient 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. Waxy flexibility c. Depersonalization d. Thought withdrawal
ANS: B Waxy flexibility is the ability to hold distorted postures for extended periods of time, as though the patient were molded in wax. Echolalia is a speech pattern. Depersonalization refers to a feeling state. Thought withdrawal refers to an alteration in thinking. REF: Page 207-208 TOP: Nursing Process: Assessment
21. The nurse assesses a patient diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia? a. Auditory hallucinations c. Poor personal hygiene b. Delusions of grandeur 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 distracters are positive symptoms of schizophrenia. See relationship to audience response question. REF: Page 207-208 (Table 12-2) TOP: Nursing Process: Assessment
36. 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. REF: Page 207-208 (Table 12-2) TOP: Nursing Process: Assessment
9. A patient diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which patient 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 patient with waxy flexibility must be fed by hand or tube, toileted, given range-of-motion exercises, and so forth to preserve physiological integrity. Higher level needs are of lesser concern. REF: Page 207 | Page 209-210 TOP: Nursing Process: Planning
16. A patient diagnosed with schizophrenia has taken fluphenazine (Prolixin) 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 c. Pseudoparkinsonism b. Hepatocellular effects 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. REF: Page 215-216 (Table 12-4) TOP: Nursing Process: Assessment
15. A newly admitted patient 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 patients to play cards with you."
ANS: C Staying with a distraught patient 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 patient hears voices is not particularly relevant at this point. Asking if the patient plans to "get away from the voices" is relevant for assessment purposes but is less helpful than offering to stay with the patient while encouraging a focus on their discussion. Suggesting playing cards with other patients shifts responsibility for intervention from the nurse to the patient and other patients. REF: Page 206-207 | Page 212-213 (Box 12-3)
7. A health care provider considers which antipsychotic medication to prescribe for a patient diagnosed with schizophrenia who has auditory hallucinations and poor social function. The patient is also overweight and hypertensive. Which drug should the nurse advocate? a. Clozapine (Clozaril) c. Olanzapine (Zyprexa) b. Ziprasidone (Geodon) d. Aripiprazole (Abilify)
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 patient with obesity or heart disease. Clozapine may produce agranulocytosis, making it a poor choice as a first-line agent. Ziprasidone may prolong the QT interval, making it a poor choice for a patient with cardiac disease. Olanzapine fosters weight gain. REF: Page 215-219 (Table 12-5) TOP: Nursing Process: Planning
34. The nurse is developing a plan for psychoeducational sessions for several adults diagnosed with schizophrenia. Which goal is best for this group? Members will: 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 patients maintain relationships with others. These relationships are important to management of the disorder. Most patients with schizophrenia think concretely, so insight development is unlikely. Not all patients with schizophrenia experience delusions. REF: Page 211-215 (Box 12-6) TOP: Nursing Process: Planning
31. A patient diagnosed with schizophrenia and auditory hallucinations anxiously tells the nurse, "The voice is telling me to do things." Select 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 patient to do is important because the command often places the patient 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. REF: Page 207-209 TOP: Nursing Process: Assessment
25. A patient 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. REF: Page 205 TOP: Nursing Process: Assessment
32. A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 1030. By 1200, the patient has difficulty swallowing and is drooling. By 1600, vital signs are 102.8° F pulse 110 respirations 26 150/90. The patient is diaphoretic. Select the nurse's best analysis and action. a. Agranulocytosis institute reverse 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. REF: Page 210 (Table 12-3) | Page 219-220
30. A patient diagnosed with schizophrenia anxiously says, "I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror." While listening, the nurse should: a. sit close to the patient. b. place an arm protectively around the patient's shoulders. c. place a hand on the patient's arm and exert light pressure. d. maintain a normal social interaction distance from the patient.
ANS: D The patient is describing phenomena that indicate personal boundary difficulties and depersonalization. The nurse should maintain appropriate social distance and not touch the patient because the patient is anxious about the inability to maintain ego boundaries and merging or being swallowed by the environment. Physical closeness or touch could precipitate panic. REF: Page 204 | Page 212-213 TOP: Nursing Process: Implementation
20. A nurse sits with a patient diagnosed with schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the nurse's best 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 patient is likely laughing in response to inner stimuli, such as hallucinations or fantasy. Focus on the hallucinatory clue (the patient's laughter) and then elicit the patient'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 patient is probably not focusing on what the nurse said in the first place. REF: Page 206-207 | Page 212-213 (Box 12-3)
23. A patient 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 c. Neologisms b. Concrete thinking d. Paranoia
ANS: D The patient'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. REF: Page 205-206 TOP: Nursing Process: Assessment
8. A patient diagnosed with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It blows away. Get it?" Select the nurse's best 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 patient's speech is loosely associated, confused, and disorganized, pretending to understand is useless. The nurse should tell the patient that he or she is having difficulty understanding what the patient is saying. If a theme is discernible, ask the patient to talk about the theme. The incorrect options tend to place blame for the poor communication with the patient. The correct response places the difficulty with the nurse rather than being accusatory. See relationship to audience response question. REF: Page 205 | Page 213-214 TOP: Nursing Process: Implementation
4. Withdrawn patients diagnosed with schizophrenia: a. are usually violent toward caregivers. b. universally fear sexual involvement with therapists. c. exhibit a high degree of hostility as evidenced by rejecting behavior. d. avoid relationships because they become anxious with emotional closeness.
ANS: D When an individual is suspicious and distrustful and perceives the world and the people in it as potentially dangerous, withdrawal into an inner world can be a defense against uncomfortable levels of anxiety. When someone attempts to establish a relationship with such a patient, the patient's anxiety rises until trust is established. There is no evidence that withdrawn patients with schizophrenia universally fear sexual involvement with therapists. In most cases, it is untrue that withdrawn patients with schizophrenia are commonly violent or exhibit a high degree of hostility by demonstrating rejecting behavior. REF: Page 211 TOP: Nursing Process: Evaluation
A nurse plans a series of psychoeducational groups for persons with schizophrenia. Which topic would take priority? A. How to complete an application for employment B. The importance of taking medication correctly C. Ways to dress and behave when attending community events D. How to give and receive compliments
B Although completing applications, dressing and behaving correctly, and giving and receiving compliments are important, correct self-management of pharmacotherapy takes priority. The patient cannot maintain remission without the appropriate medication.
A patient's dose of haloperidol (Haldol) was increased earlier today. The patient now is experiencing laryngeal dystonia. What is the nurse's priority action? A. Document the finding B. Maintain a patent airway C. Offer oral fluids to the patient D. Engage the patient in an alternative activity
B Laryngeal dystonia is associated with an acute dystonic reaction and may impair the integrity of the patient's airway. The nurse will document the events after they are managed. Oral fluids could be aspirated. Immediate nursing action is indicated; it would be inappropriate to try to engage the patient in an alternate activity.
Which of the following symptoms would alert a health care provider to a possible diagnosis of schizophrenia in a young adult male? A. Excessive sleeping with disturbing dreams B. Hearing voices telling him to hurt his roommate C. Withdrawal from college because of failing grades D. Chaotic and dysfunctional relationships with his family and peers
B People diagnosed with schizophrenia all have at least one psychotic symptom, such as hallucinations, delusional thinking, or disorganized speech. Excessive sleeping, failing grades, and chaotic and dysfunctional relationships do not describe schizophrenia but could be caused by a number of problems.
In a clinical interview conducted at a community health care center, the nurses observe that a schizophrenic patient is very sensitive and feels extremely guilty about his or her previous actions. What is the appropriate diagnosis by a nurse about the patient? A. The patient has impaired verbal communication. B. The patient has risk for self-directed violence. C. The patient is showing positive symptoms of schizophrenia. D. The patient is a victim of child abuse.
B The patient with schizophrenia show negative symptoms such as self-blaming, guilt, and becoming sensitive. It indicates that the patient is at risk for self-directed violence and can do self-harm. Impaired verbal communication is characterized by dissociative ideas. Positive symptoms of schizophrenia include hallucination and associative looseness. Feeling guilty and being sensitive are negative symptoms of schizophrenia. Schizophrenia is not associated with a history of child abuse.
A patient diagnosed with disorganized schizophrenia would have greatest difficulty when the nurse A. Interacts with a neutral attitude B. Uses concrete language C. Gives multistep directions D. Provides nutritional supplements
B The thought processes of the patient with disorganized schizophrenia are severely disordered, and severe perceptual problems are present, making it extremely difficult for the patient to understand what others are saying. All communication should be simple and concrete and may need to be repeated several times.
Which symptom seen in a schizophrenic patient can be categorized as a positive symptom? A. Loss of motivation B. Impaired judgment C. Delusions D. Dysphoria
C The behavioral traits not normally found in healthy patients are called positive symptoms of schizophrenia. They include delusions, hallucinations, bizarre behavior, and paranoia. The behaviors that the patient lacks compared to healthy people are negative symptoms, such as loss of motivation and alogia (poverty of thought or inability to speak). Impaired judgment and illogical thinking are the cognitive symptoms associated with schizophrenia. Dysphoria and suicidal intentions are affective symptoms of schizophrenia. Affective symptoms involve emotions and their expression.
A nurse assesses a patient diagnosed with schizophrenia who states, "Aliens are trying to inject me with their DNA." The nurse documents the patient's comment and applies which term? A. Anosognosia B. Affective blunting C. Positive symptoms D. Negative symptoms
C The patient's comment indicates delusional thinking, which is a positive symptom of schizophrenia. Anosognosia refers to an inability to realize an illness exists. Affective blunting relates to the patient's outward expression of emotion. Negative symptoms include social isolation, anergia, lack of motivation, blunted affect, and inattention to personal hygiene.
Which side effect of antipsychotic medication is generally nonreversible? A. Anticholinergic effects B. Pseudoparkinsonism C. Dystonic reaction D. Tardive dyskinesia
D Tardive dyskinesia is not always reversible with discontinuation of the medication and has no proven cure. The side effects in anticholinergic effects, pseudoparkinsonism, and dystonic reaction often appear early in therapy and can be minimized with treatment.
