Flashcards in Chapter 16: Schizophrenia Spectrum and Other Psychotic Disorders Deck (40)
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 providers who are qualified to help you.”
ANS - B
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 behaviour as which of the following?
b. An idea of reference
c. A delusion of infidelity
d. An auditory hallucination
ANS - B
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?
ANS - B
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
Which of the following patient statements implies a hallucination that requires the nurse to implement safety measures?
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
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
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)
b. Ziprasidone (Zeldox)
c. Olanzapine (Zyprexa)
d. Aripiprazole (Abilify)
ANS - D
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.”
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. Clear messages and honesty are a vital part of working effectively in psychiatric mental health nursing. An honest response lets the person know that the nurse does not understand, would like to understand, and can be trusted to be honest. 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
A patient diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which patient needs are of priority importance?
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 which of the following?
a. The patient demonstrates increased interest in the environment by the end of week 1.
b. The patient performs self-care activities with coaching by the end of day 3.
c. The patient gradually takes the initiative for self-care by the end of week 2.
d. The patient accepts tube feeding without objection by day 2.
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, or describe total care versus maintenance of self-care.
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?
b. Waxy flexibility
d. Thought withdrawal
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
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.
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 levelling 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.
Which of the following is true for withdrawn patients diagnosed with schizophrenia?
a. They are usually violent toward caregivers.
b. They universally fear sexual involvement with therapists.
c. They exhibit a high degree of hostility as evidenced by rejecting behaviour.
d. They avoid relationships because they become anxious with emotional closeness.
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 defence 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 behaviour.
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.”
Staying with a distraught patient who is hearing voices serves several purposes: ongoing observation, the opportunity to provide reality orientation, a means of helping to 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 (Modecate) 5 mg po bid for 3 weeks. The nurse now observes a shuffling propulsive gait, a masklike face, and drooling. Which term applies to these symptoms?
a. Neuroleptic malignant syndrome
b. Hepatocellular effects
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.
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
b. Tardive dyskinesia
c. Waxy flexibility
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.
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.
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.
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?
b. Tardive dyskinesia
c. Tourette’s 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 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; and anticholinergic effects include dry mouth, blurred vision, flushing, constipation, and dry eyes
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.”
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.
The nurse assesses a patient diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia?
a. Auditory hallucinations
b. Delusions of grandeur
c. Poor personal hygiene
d. Psychomotor agitation
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.
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 behaviour, 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 list the positive symptoms of schizophrenia that might be apparent during the acute stage of the illness.
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
b. Concrete thinking
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.
A patient diagnosed with schizophrenia begins a new prescription for lurasidone (Latuda). The patient is 168 cm and currently weighs 95 kg. 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.
A patient diagnosed with schizophrenia says, “It’s beat. Time to eat. No room for the cat.” What type of verbalization is evident?
b. Idea of reference
c. Thought broadcasting
d. Associative looseness
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.
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.
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?
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.
A patient diagnosed 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, “My computer is sending out infected radiation beams.” The nurse assesses this information as an indication of which of the following?
a. The need for psychoeducation
b. Medication noncompliance
c. Chronic deterioration
Signs of potential relapse include feeling tense, difficulty concentrating, trouble sleeping, increased withdrawal, and increased bizarre or magical thinking. Medication noncompliance may not be implicated. Relapse can occur even when the patient is taking medication regularly. Psychoeducation is more effective when the patient’s symptoms are stable. Chronic deterioration is not the best explanation.
A patient diagnosed with schizophrenia begins to talks about “macnabs” hiding in the warehouse at work. The term macnabs should be documented as which of the following?
a. A neologism
b. Concrete thinking
c. Thought insertion
d. An idea of reference
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 the belief that the 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.