Ch. 17 Flashcards
(38 cards)
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.
“No, 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.
DIF: Cognitive Level: Application REF: Pages: 314-316
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:
a.
echolalia
b.
idea of reference
c.
delusion of infidelity
d.
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.
DIF: Cognitive Level: Comprehension REF: Page: 306
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?
a.
Disorganized
b.
Dangerous
c.
Supportive
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.
DIF: Cognitive Level: Comprehension REF: Page: 309|Page: 316
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?
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.
DIF: Cognitive Level: Application REF: Pages: 320-325
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?
a.
Use of a long-acting antipsychotic preparation
b.
Addition of a benzodiazepine, such as lorazepam (Ativan)
c.
Adjunctive use of an antidepressant, such as amitriptyline (Elavil)
d.
Prolonged hospitalization; this patient is not ready for discharge
ANS: A
Medications such as fluphenazine decanoate and haloperidol decanoate are long-acting forms of antipsychotic medications. They are administered by depot injection every 2 to 4 weeks, thus reducing daily opportunities for noncompliance. The other options do not address the patient’s dislike of taking pills.
DIF: Cognitive Level: Application REF: Pages: 320-325
A patient’s care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating?
a.
Aloofness, haughtiness, suspicion
b.
Darting eyes, tilted head, mumbling to self
c.
Elevated mood, hyperactivity, distractibility
d.
Performing rituals, avoiding open places
ANS: B
Clues to hallucinations include looking around the room as though to find the speaker; tilting the head to one side as though intently listening; and grimacing, mumbling, or talking aloud as though responding conversationally to someone.
DIF: Cognitive Level: Application REF: Pages: 307-308
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?
a.
clozapine (Clozaril)
b.
ziprasidone (Geodon)
c.
olanzapine (Zyprexa)
d.
aripiprazole (Abilify)
ANS: D
Aripiprazole is an atypical antipsychotic medication that is 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 levels, 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.
DIF: Cognitive Level: Analysis REF: Pages: 320-325
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.
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.
DIF: Cognitive Level: Application REF: Pages: 306-307
A patient with catatonic schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which patient needs are of priority importance?
a.
Psychosocial
b.
Physiologic
c.
Self-actualization
d.
Safety and security
ANS: B
Physiologic needs must be met to preserve life. A patient who is semistuporous must be fed by hand or tube, toileted, and given range-of-motion exercises to preserve physiologic integrity. Safety needs rank second to physical needs. Higher level needs are of lesser concern.
DIF: Cognitive Level: Application REF: Page: 308|Pages: 312-313
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:
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 the patient’s ability to perform self-care tasks independently, such as feeding, bathing, dressing, and toileting. Performing the tasks with coaching by the nursing staff denotes improvement over the complete inability to perform the tasks. The incorrect options are not directly related to self-care activities; they are difficult to measure and are unrelated to maintaining nutrition.
DIF: Cognitive Level: Application REF: Page: 308|Pages: 312-313
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?
a.
Echolalia
b.
Waxy flexibility
c.
Depersonalization
d.
Thought withdrawal
ANS: B
Waxy flexibility is the ability to hold distorted postures for extended periods, 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.
DIF: Cognitive Level: Comprehension REF: Pages: 308-310
Which patient with schizophrenia would be expected to have the lowest score in global assessment of functioning?
a.
39 years old; paranoid ideation since age 35 years
b.
32 years old; diagnosed as catatonic at age 24 years; stable for 3 years
c.
19 years old; diagnosed with undifferentiated schizophrenia at age 17
d.
40 years old; disorganized schizophrenia since age 18; frequent relapses
ANS: D
Disorganized schizophrenia represents the most regressed and socially impaired of all the schizophrenias. The 40-year-old patient who has had disorganized schizophrenia since 18 years of age could logically be expected to have the lowest global assessment of functioning. In addition, the patient has been ill for a number of years and has had frequent relapses. The 39-year-old patient who has had paranoid ideation since 35 years of age could be expected to have the highest score, because paranoid schizophrenia of short duration may be less impairing than other types. The patient who was diagnosed as catatonic at the age of 24 years has been stable for more than 3 years, suggesting a higher functional ability. The 19-year-old patient who was diagnosed with undifferentiated schizophrenia at 17 years of age has been ill for only 2 years, and disability in undifferentiated schizophrenia remains fairly stable over time.
DIF: Cognitive Level: Analysis REF: Page: 304|Page: 312
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?
a.
Allowing the patient to have supervised access to food vending machines
b.
Allowing the patient to telephone 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 considered aggressive and usually promote violence. Patients perceive foods in sealed containers, packages, or natural shells as being safe.
DIF: Cognitive Level: Analysis REF: Page: 306|Page: 316
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 visit every other day for 1 week; stay with the 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.
DIF: Cognitive Level: Application REF: Page: 309|Page: 312|Page: 318
Withdrawn patients with schizophrenia:
a.
Universally fear sexual involvement with therapists.
b.
Are socially disabled by the positive symptoms of schizophrenia.
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. No evidence suggests that withdrawn patients with schizophrenia universally fear sexual involvement with therapists. In most cases, it is not considered true that withdrawn patients with schizophrenia are socially disabled by the positive symptoms of schizophrenia or exhibit a high degree of hostility by demonstrating rejecting behavior.
DIF: Cognitive Level: Comprehension REF: Pages: 305-308
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.
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.
DIF: Cognitive Level: Application REF: Pages: 313-315
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?
a.
Neuroleptic malignant syndrome
b.
Hepatocellular effects
c.
Pseudoparkinsonism
d.
Akathisia
ANS: C
Pseudoparkinsonism induced by antipsychotic medication mimics the symptoms of Parkinson disease. It frequently appears within the first month of treatment. Hepatocellular effects would produce abnormal liver test results. Neuroleptic malignant syndrome is characterized by autonomic instability. Akathisia produces motor restlessness.
DIF: Cognitive Level: Application REF: Pages: 325-326
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?
a.
Acute dystonic reaction
b.
Tardive dyskinesia
c.
Waxy flexibility
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 that require 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 observed in catatonic schizophrenia. Akathisia is evidenced by internal and external restlessness, pacing, and fidgeting.
DIF: Cognitive Level: Application REF: Page: 326
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?
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; therefore the intramuscular route is best. In this case, the best option given is diphenhydramine.
DIF: Cognitive Level: Analysis REF: Page: 326
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?
a.
Agranulocytosis
b.
Tardive dyskinesia
c.
Tourette syndrome
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 observed. 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 syndrome is a condition in which tics are present. Anticholinergic effects include dry mouth, blurred vision, flushing, constipation, and dry eyes.
DIF: Cognitive Level: Application REF: Pages: 320-327
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.
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. Focusing on the hallucinatory clue (i.e., the patient’s laughter) and then eliciting the patient’s observation is best. 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 has said in the first place.
DIF: Cognitive Level: Application REF: Page: 315
Which symptoms are expected for a patient with disorganized schizophrenia?
a.
Extremes of motor activity, from excitement to stupor
b.
Social withdrawal and ineffective communication
c.
Severe anxiety with ritualistic behavior
d.
Highly suspicious, delusional behavior
ANS: B
Patients with disorganized schizophrenia demonstrate the most regressed and socially impaired behaviors of the schizophrenias. Communication is often incoherent, with silly giggling and loose associations predominating. Highly suspicious, delusional behavior relates more to paranoid schizophrenia. Extremes of motor activity, from excitement to stupor, relates to catatonic schizophrenia. Severe anxiety and ritualistic behaviors relate to obsessive-compulsive disorder.
DIF: Cognitive Level: Comprehension REF: Page: 310
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, which are the symptoms 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.
DIF: Cognitive Level: Comprehension REF: Pages: 310-311
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?
a.
Poverty of content
b.
Concrete thinking
c.
Neologisms
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.
DIF: Cognitive Level: Application REF: Page: 309
