Nursing Care
A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client's safety?
A. Assess for medication noncompliance
B. Note escalating behaviors and intervene immediately
C. Interpret attempts at communication
D. Assess triggers for bizarre, inappropriate behaviors
ANS: B
The nurse should note escalating behaviors and intervene immediately to maintain this client's safety. Early intervention may prevent an aggressive response and keep the client and others safe.
Which patient behavior would support the diagnosis of residual schizophrenia with negative symptoms?
A. Communicating using only rhyming phases
B. Claims that worms are crawling in my brain
C. Maintaining both arms suspended awkwardly overhead
D. Shows no emotion when telling the story of a sisters recent death
ANS: D
Blunted affect is considered a negative symptom. The other symptoms would be classified as positive symptoms.
Because of the cognitive disturbances associated with schizophrenia, which technique will be useful as the nurse teaches a patient about self-management?
A. Use only verbal instruction
B. Teach material in small segments
C. Offer opportunities for making numerous choices
D. Plan the teaching for a time when the patient has been recently medicated.
B. Teach material in small segments
Patients with cognitive disturbances should be taught small blocks of information at a time and given frequent reinforcement. Both verbal and visual materials should be used since processing of verbal stimuli may be more impaired. Teaching should be scheduled when the patient is most alert as medications may make them drowsy. A large number of choices may be confusing for the person, but a few simple choices may be included.
A patient prescribed an antipsychotic medication develops a high fever, unstable blood pressure, and muscle rigidity. Her next dose of medication is due. The nurse should:
A. Administer the medication and monitor the vital signs every 4 hours
B. Give a lower dose of the medication for 24 hours and monitor the blood pressure
C. Prepare to administer a prn dose of the anticholinergic drug benztropine (Cogentin)
D. Hold the medication and immediately describe the patients symptoms to the doctor
ANS: D
These symptoms could be related to a possibly fatal disorder called neuroleptic malignant syndrome (NMS), and the nurse should hold the medication and contact the doctor immediately.
The other options are inappropriate in light of the seriousness of the situation.
Which action would the nurse take to establish a trusting relationship with a client diagnosed with schizophrenia spectrum disorder?
Establish personal contact with family members
Be reliable, honest, and consistent during interactions
Share limited personal information
Sit close to the client to establish rapport
Answer: 2
Rationale: The nurse can enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia spectrum disorder by being reliable, honest, and consistent during interactions. The nurse should also convey acceptance of theclient’s needs and maintain a calm attitude.
12. The nurse is caring for a client with schizophrenia spectrum disorder who is experiencing a flat affect, paranoid delusions, anhedonia, anergia, neologisms, and echolalia. Which statement correctly differentiates the client’s positive and negative symptoms of schizophrenia?
Paranoid delusions, anhedonia, and anergia are positive symptoms of
schizophrenia.
Paranoid delusions, neologisms, and echolalia are positive symptoms of
Schizophrenia.
Paranoid delusions, anergia, and echolalia are negative symptoms of schizophrenia.
Paranoid delusions, flat affect, and anhedonia are negative symptoms of schizophrenia.
Answer: 2
Rationale: The nurse should recognize that positive symptoms of schizophrenia include, but are not limited to, paranoid delusions, neologisms, and echolalia.
The parent of a client with schizophrenia asks the nurse when his son would be completely cured. The nurse responds with which of the following?
A. Give the medications at least 6 months for the symptoms to disappear
B. Schizophrenia can be treated but not cured
C. It depends on his response to the medication and the support he is getting
D. All of the above
B. Schizophrenia can be treated but not cured
The client with schizophrenia has recently begun a new medication, clozapine (Clozaril). Which laboratory result would reveal a potentially fatal side effect of this medication?
1. Elevated white blood cell count
2. Elevated bleeding times
3. Low platelet count
4. Low absolute neutrophil count
Answer: 4
Rationale: A low absolute neutrophil count is indicative of agranulocytosis, a potentially fatal disorder in which the client’s white blood cell count and neutrophil count drops to extremely low levels.
A client diagnosed with schizophrenia spectrum disorder states, “Can’t you hear him? It’s the devil. He’s telling me I’m going to hell.” Which is the most appropriate nursing response?
“Did you take your medicine this morning?”
“You are not going to hell. You are a good person.”
“The voices must sound scary, but I do not hear any voices.”
“The devil only talks to people who are receptive to his influence.”
Answer: 3
Rationale: The most appropriate nursing response is to reassure the client while not reinforcing the hallucination. Reminding the client that “the voices” are not real will prevent validation of the hallucination. It is also important for the nurse to connect with the client’s fears and inner feelings.
A 19-year-old patient is admitted for the second time in 9 months and is acutely psychotic with a diagnosis of undifferentiated schizophrenia. The patient sits alone rubbing her arms and smiling. She tells the nurse her thoughts cause earthquakes and that the world is burning. The nurse assesses the primary deficit associated with the patients condition as:
A. Social Isolation
B. Disturbed thinking
C. Altered mood status
D. Poor impulse control
ANS: B
The nurse interprets the patients statements that were not reality-based as indicating disturbed thought processes. Social isolation is not the primary patient problem. No data exist to support the other options.
13. The aging client takes an antipsychotic for schizophrenia spectrum disorder and a beta-adrenergic blocking agent for hypertension. Based on an understanding of the combined side effects of these drugs, which statement by a nurse is most appropriate?
“Make sure you concentrate on taking slow, deep, cleansing breaths.”
“Watch your diet and try to engage in some regular physical activity.”
“Rise slowly when you change position from lying to sitting or sitting to standing.”
“Wear sunscreen and try to avoid midday sun exposure.”
Answer: 3
Rationale: The most appropriate statement by the nurse is to instruct the client to rise slowly when changing positions. Antipsychotic medications and beta blockers cause a decrease in blood pressure. When given in combination, the additive effect of these drugs places the client at risk for developing orthostatic hypotension.
A nurse assesses a patient receiving haloperidol [Haldol]. The nurse notices that the patient is shifting in the chair, rocking back and forth, and tapping both feet constantly. What is the most accurate term to document these findings?
a) Dystonia
b) Tardive dyskinesia
c) Parkinsonism
d) Akathisia
d) Akathisia
Haloperidol is a traditional antipsychotic medication with the adverse effects of extrapyramidal symptoms. Akathisia, or motor restlessness, is an extrapyramidal symptom. Dystonia manifests as severe spasm of the muscles of the tongue, face, neck, or back and may include upward deviation of the eyes, severe cramping, and impaired respiration. Tardive dyskinesia presents with involuntary twisting, writhing, wormlike movements of the tongue and face, lip smacking, and tongue flicking. Parkinsonism appears with bradykinesia, masklike facies, drooling, tremor, rigidity, shuffling gait, and stooped posture.
a. Maintain eye contact
b. Isolate the patient
c. Speak simply but louder than normal
d. Touch the patient
Answer: B
Rationale: Traditional interventions often focus on isolating patient, but intense
sensory confusion in isolation may reinforce psychosis. Using touch(with patient’s permission) can help with sensory validation may help to override abnormal sensory processes in brain
The client with schizophrenia has recently begun a new medication, clozapine (Clozaril). Which signs and symptoms of a potentially fatal side effect will the nurse teach the client about?
Blurring vision, dry mouth, and constipation
Sore throat, fever, and malaise
Tremor, shuffling gait, and rigidity
Fine tremor, tinnitus, and nausea
Answer: 2
Rationale: Sore throat, fever, and malaise are symptoms of agranulocytosis, which is a potentially fatal disorder in which the client’s white blood cell count drops to extremely low levels. This places the client at great risk for infections.
A client with schizophrenia is prescribed second-generations antipsychotic. The client's mother asks, "About how long will it take until we see any changes in his symptoms?" Which response by the nurse would be most appropriate?
1. "Generally, it takes about one to two weeks to be effective in changing symptoms"
2. "You should see improvement in about 36 to 48 hours"
3. "His symptoms should subside almost immediately"
4. "It will take about 6 to 12 weeks until the drug is effective"
1. "Generally, it takes about one to two weeks to be effective in changing symptoms"
Generally, it takes about one to two weeks for antipsychotic drugs to effect a change in symptoms.
During the stabilization period, the selected drug should be given an adequate trial, generally 6 to 12 weeks, before considering a change in the drug prescription. If treatment effects are not seen, another antipsychotic agent may be tried
What is the basis for the reduction in disturbed thought processes when a patient is administered haloperidol (Haldol)?
A. Reduction in the number of brain cells that crave dopamine
B. Dopamine receptors are blocked, making dopamine less available
C. Dopamine receptors are enhanced, making more dopamine available
D. Medication causes an increased cellular production of dopamine
ANS: B
Excess dopamine is responsible for symptoms of psychosis such as delusions and hallucinations. Blocking dopamine receptors will result in reduction of primary symptoms. The other options do not reflect the action of typical antipsychotic medications
Which modalities should a nurse recognize as integral parts of a treatment program when planning care for clients diagnosed with schizophrenia spectrum disorder? (Select all that apply.)
Group therapy
Medication management
Deterrent therapy
Supportive family therapy
Social skills training
Answer: 1,2,4,5
Rationale: The nurse should recognize that group therapy plays an integral part of treatment programs for clients diagnosed with schizophrenia spectrum disorder.The nurse should recognize that medication management plays an integral part of treatment programs for clients diagnosed with schizophrenia spectrum disorder. The nurse should recognize that supportive family therapy plays an integral part of treatment programs for clients diagnosed with schizophrenia spectrum disorder. The nurse should recognize that social skills training plays an integral part of treatment programs for clients diagnosed with schizophrenia spectrum disorder.
During an admission assessment, a nurse asks a client diagnosed with schizophrenia, "Have you ever felt that certain objects or persons have control over your behavior?" The nurse is assessing for which type of thought disruption?
A. Delusions of persecution
B. Delusions of influence
C. Delusions of reference
D. Delusions of grandeur
ANS: B
The nurse is assessing the client for delusions of influence when asking if the client has ever felt that objects or persons have control of the client's behavior. Delusions of control or influence are manifested when the client believes that his or her behavior is being influenced.
An example would be if a client believes that a hearing aid receives transmissions that control personal thoughts and behaviors.
After teaching a group of nursing students about neurotransmitters associated with schizophrenia, the nursing instructor determines that the education was successful when the students verify which of the following as playing a role in the positive symptoms of schizophrenia?
1. Glutamate
2. Serotonin
3. Dopamine
4. Gamma-aminobutyric acid (GABA)
3. Dopamine
Positive symptoms of schizophrenia, specifically hallucinations and delusions, are thought to be related to dopamine hyperactivity. Studies are revealing that schizophrenia does not result from the dysregulation of a single neurotransmitter or biogenic amine, such as norepinephrine or serotonin. Hypothesis suggests a role for glutamate and GABA. However, dopamine dysfunction is also thought to be involved in psychosis with other disorders.
Neuroleptic malignant syndrome (NMS) is a life-threatening reaction to antipsychotic drugs. Which of the following symptoms are associated with neuroleptic malignant syndrome? SATA
Sudden high fever
Bradycardia
Lead pipe muscle rigidity
GI distress
BP fluctuations
Answers: A,C,E
Rationale: Symptoms include sudden high fever, tachycardia, BP fluctuations, lead pip muscle rigidity, slow movements