Chapter 12 Flashcards
- 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.
- 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.
b. an idea of reference.
c. a delusion of infidelity.
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.
- 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.
- 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.
- 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.
- A patient’s care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating?
a. Detachment and overconfidence
b. Darting eyes, tilted head, mumbling to self
c. Euphoric mood, hyperactivity, distractibility
d. Foot tapping and repeatedly writing the same phrase
ANS: B
Clues to hallucinations include eyes looking around the room as though to find the speaker, tilting the head to one side as though listening intently, and grimacing, mumbling, or talking aloud as though responding conversationally to someone.
- A 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.
- 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.
- A patient diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which patient needs are of priority importance?
a. Self-esteem c. Physiological
b. Psychosocial 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.
- A patient diagnosed with schizophrenia demonstrates little spontaneous movement and has waxy flexibility. The patient’s activities of daily living are severely compromised. An appropriate outcome would be that the patient will:
a. demonstrate increased interest in the environment by the end of week 1.
b. perform self-care activities with coaching by the end of day 3.
c. gradually take the initiative for self-care by the end of week 2.
d. accept tube feeding without objection by day 2.
ANS: B
Outcomes related to self-care deficit nursing diagnoses should deal with increasing ability to perform self-care tasks independently, such as feeding, bathing, dressing, and toileting. Performing the tasks with coaching by nursing staff denotes improvement over the complete inability to perform the tasks. The incorrect options are not directly related to self-care activities, difficult to measure, and unrelated to maintenance of nutrition.
- A 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 c. Depersonalization
b. Waxy flexibility 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.
- 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.
- 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.
- 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.
- 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.
- 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
b. Hepatocellular effects
c. Pseudoparkinsonism
d. Akathisia
ANS: C
Pseudoparkinsonism induced by antipsychotic medication mimics the symptoms of Parkinson’s disease. It frequently appears within the first month of treatment and is more common with first-generation antipsychotic drugs. Hepatocellular effects would produce abnormal liver test results. Neuroleptic malignant syndrome is characterized by autonomic instability. Akathisia produces motor restlessness.