Mental Health Chapter 17
A patient with paranoid schizophrenia is hospitalized after arguing with co-workers and threatening to harm them. The patient is aloof and 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.
Risk for other-directed violence, Disturbed thought processes
An acutely violent patient 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 is thrust forward, and the patient is drooling. Which intervention by the nurse is indicated?
Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record.
When a patient with paranoid 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 common side effects should the nurse validate with the patient?
Sedation and muscle stiffness
A patient with schizophrenia has been stable for a year; however, the family now reports the patient is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The patient says, "Volmers are hiding in the house." The nurse can correctly assess this information as an indication of:
relapse
The family members of a patient newly diagnosed with paranoid schizophrenia state that they do not understand what has caused the illness. The nurse's response should be based on which models? Select all that apply.
Neurobiological, Genetic
A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 10:30 AM. By noon, the patient has difficulty swallowing and is drooling. By 4:00 PM, vital signs are body temperature, 102.8° F; pulse, 110 beats per minute; respirations, 26 breaths per minute; and blood pressure, 150/90 mm Hg. The patient is diaphoretic. Select the nurse's best analysis and action.
Neuroleptic malignant syndrome. Immediately notify the health care provider.
A patient with schizophrenia has auditory hallucinations, delusions of grandeur, poor personal hygiene, and motor agitation. Which assessment finding would the nurse regard as a negative symptom of schizophrenia?
Poor personal hygiene
A person has had difficulty keeping a job because of arguing with coworkers 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.
"Feeling that people want to destroy you must be very frightening."
A patient with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It blows away. Get it?" Select the nurse's best response
"I am having difficulty understanding what you are saying."
A newly admitted patient with schizophrenia says, "The voices are bothering me. They yell and tell me I'm bad. I have got to get away from them." Select the nurse's most helpful reply.
"I'll stay with you. Focus on what we are talking about, not the voices."
A patient with schizophrenia and auditory hallucinations anxiously tells the nurse, "The voice is telling me to do things." Select the nurse's priority assessment question.
"What is the voice telling you to do?"
A nurse sits with a patient diagnosed with disorganized schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the nurse's best response.
"You're laughing. Tell me what's happening."
Which patient with schizophrenia would be expected to have the lowest score in global assessment of functioning?
40 years old; disorganized schizophrenia since age 18; frequent relapses
A patient with schizophrenia is acutely 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 is thrust forward, and the patient is drooling. Which problem is most likely?
Acute dystonic reaction
A patient with delusions of persecution about being poisoned has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the patient?
Allowing the patient to have supervised access to food vending machines
A patient diagnosed with disorganized schizophrenia says, "It's beat. Time to eat. No room for the cat." What type of verbalization is evident?
Associative looseness
Withdrawn patients with schizophrenia:
Avoid relationships because they become anxious with emotional closeness.
A patient diagnosed with paranoid 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?
Dangerous
A patient's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating?
Darting eyes, tilted head, mumbling to self
A patient 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?
Paranoia
A patient with catatonic schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which patient needs are of priority importance?
Physiologic
A patient with schizophrenia has taken fluphenazine (Prolixin) 5 mg orally twice daily for 3 weeks. The nurse now assesses a shuffling propulsive gait, a masklike face, and drooling. Which term applies to these symptoms?
Pseudoparkinsonism
The family of a patient with undifferentiated schizophrenia is unfamiliar with the illness and the family's role in recovery. Which type of therapy should the nurse recommend?
Psychoeducational
Which symptoms are expected for a patient with disorganized schizophrenia?
Social withdrawal and ineffective communication
A patient has taken trifluoperazine (Stelazine) 30 mg/day orally 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?
Tardive dyskinesia
A nurse at the mental health clinic plans a series of psychoeducational groups for persons with schizophrenia. Which two topics would take priority?
The importance of correctly taking your medication, Ways to quit smoking
A nurse works with a patient with paranoid schizophrenia regarding the importance of medication management. The patient repeatedly says, "I don't like taking pills." Family members say they feel helpless to foster compliance. Which treatment strategy should the nurse discuss with the health care provider?
Use of a long-acting antipsychotic preparation
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.
Visit daily for 4 days, then visit every other day for 1 week; stay with the patient for 20 minutes; accept silence; state when the nurse will return.
A nurse observes a patient who is in a catatonic state and 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?
Waxy flexibility
A patient with schizophrenia begins a new prescription for lurasidone HCl (Latuda). The patient is 5', 6" tall and currently weighs 204 pounds. Which topic is most important for the nurse to include in the teaching plan related to this medication?
Weight management strategies
What assessment findings mark the prodromal stage of schizophrenia?
Withdrawal, misinterpreting, poor concentration, and preoccupation with religion
A health care provider considers which antipsychotic medication to prescribe for a patient with schizophrenia who has auditory hallucinations and poor social functioning. The patient is also overweight and has hypertension. Which drug should the nurse advocate?
aripiprazole (Abilify)
A newly admitted patient diagnosed with paranoid 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:
idea of reference
A patient 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:
maintain a normal social interaction distance from the patient.
A patient diagnosed with paranoid schizophrenia angrily tells a nurse, "You act like a homosexual. No one trusts you or wants to be around you." Select the most likely analysis. The patient:
may be projecting homosexual urges.
A patient with schizophrenia begins to talks about "volmers" hiding in the warehouse at work. The term "volmers" should be documented as:
neologism
A patient 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 expects a change to which medication?
olanzapine (Zyprexa)
A patient with catatonic schizophrenia is semistuporous, demonstrates little spontaneous movement, and has waxy flexibility. The patient's activities of daily living are severely compromised. An appropriate outcome is that the patient will:
perform self-care activities with coaching by the end of day 3.
