Question 1

A male patient diagnosed with paranoid schizophrenia typically relates effectively with female staff but angrily tells the male nurse,"You act like a homosexual.None of the men trust you or want to be around you." The nurse,who is heterosexual,is perplexed by the patient's statements and discusses the event with his mentor.Which explanation most likely underlies the patient's behavior?

Accepted Answer

Patients with paranoid ideation unconsciously use the defense mechanism projection to deal with unacceptable,anxiety-producing ideas and impulses,in this case homosexual urges.Although the behavior seems hostile,the root cause of the behavior is the patient's homosexual urges rather than hostility.Patients who exhibit paranoid ideation may fear rejection or abandonment,but the data here do not indicate fear of rejection,and the patient's relationships with female staff suggest he does not fear rejection.Although the patient may be uncomfortable with intimacy,the focus on sexual identity of a same-sex staff member suggests the bigger issue involves the patient's own sexuality or sexual urges.

Question 2

A patient is noted to be bending over backward in the group room.A peer asks what he is doing,and he replies,"People say they are bending over backwards to help me,so I am bending over backwards to help myself." This is an example of:

Accepted Answer

Abstract thinking is the ability to think in a nonliteral way and is essential for tasks such as understanding symbolism and abstract concepts such as love or time.Concrete thinking is the absence of abstract thinking,or literal thinking,and is seen here in the patient's interpreting the expression literally and actually bending over to help himself.Impaired reality testing is an inability to figure out whether a perception or thought is based in reality.Boundary impairment is difficulty telling where one's self begins or ends or how one is distinct from others or one's surroundings.

Question 3

At 11:00 AM,a patient with schizophrenia who exhibits concrete thinking asks the nurse for PRN acetaminophen (Tylenol).However,he last had it at 8:00 AM,and it is ordered only every 4 hours.Which nursing response would be most therapeutic?

Accepted Answer

Persons who think concretely have difficulty understanding and using abstract concepts such as the passage of time.Schizophrenia itself also interferes with one's ability to judge the passage of time.Therefore,giving the patient the needed information in the most concrete (literal,specific)manner possible is desirable,and telling him "when the hands of the clock both point straight up" is the most specific response here.Letting the patient know when it is time makes the patient dependent on the nurse and removes an opportunity to practice a needed skill.It also leaves the patient without any way to judge when the nurse might next give him the medication,which is likely to increase his anxiety.

Question 4

The physician and advanced practice nurse are considering which antipsychotic medication to prescribe for a patient with schizophrenia who demonstrates auditory hallucinations,apathy,anhedonia,and poor social functioning.The patient is overweight and has hypertension.Bearing these facts in mind,the drug the nurse should advocate would be:

Accepted Answer

Aripiprazole is a new 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.Haloperidol is unlikely to be effective against negative symptoms.Olanzapine fosters weight gain.

Question 5

The family of a patient with schizophrenia who has been stable for a year reports to the community mental health nurse that the patient reports feeling tense and having difficulty concentrating.He sleeps only 3 to 4 hours nightly and has begun to talk about creatures called "volmers" hiding in the warehouse where he works and undoing his work each night.This information most likely suggests:

Accepted Answer

Signs of potential relapse include feeling tense,difficulty concentrating,trouble sleeping,increased withdrawal,increased bizarre or magical thinking,and a general worsening of the patient's residual symptoms or a return of previous symptoms.The patient is more symptomatic,and medication nonadherence may be a contributing factor,but there is no information to indicate that the patient has been nonadherent (relapse can occur even when the patient is taking medication regularly).A lack of understanding of one's illness and treatment would not itself lead to the presentation described here,and psychoeducation is better delivered when the patient's symptoms are stable.In this case,the symptoms have worsened and/or new symptoms have been added;this suggests a change is occurring rather than the continued presentation of chronic symptoms.

Question 6

The physician prescribes haloperidol (Haldol),a first-generation antipsychotic drug,for a patient with schizophrenia who displays delusions,hallucinations,apathy,and social isolation.Which symptoms should most be monitored to evaluate the expected improvement from this medication?

Accepted Answer

First-generation (typical)antipsychotics are generally effective improving positive symptoms such as hallucinations and delusions,but they are much less helpful for negative symptoms such as affective flattening,alogia,attention deficits,anhedonia,and asociality.The atypical (second-generation and later)antipsychotic medications target both the negative and positive symptoms of schizophrenia.

Question 7

A patient with many positive symptoms of schizophrenia,whose behavior is disorganized and who is highly anxious,tells the nurse in the psychiatric emergency department,"You have got to help me.I do not know what is going on.I think someone is trying to wipe me out.I have to get a gun." The patient,a college student,lives alone and has no family or support system in the immediate area.He has not left his room in 2 weeks,has not eaten in several days,and is unkempt.Of the available treatment settings,the nurse should recommend:

Accepted Answer

The patient presents with significant psychiatric symptoms that will require further assessment and intensive treatment of a type not often available outside of an inpatient mental health unit.He will also require a 24-hour locked setting until he responds to treatment;otherwise he could elope to obtain the gun and use it to protect himself against whomever he might believe is a threat to him (with potentially disastrous consequences).The patient has no support system to provide care at home,and both partial hospitalization and day treatment would leave the patient without structure and support for at least 12 hours daily;neither would provide the level of security needed to preserve the safety of the patient and others.A residential crisis center that is unlocked would not provide for safety needs,and most such facilities are designed for persons who have already been fully assessed and begun on medications.

Question 8

A patient has schizophrenia and is troubled by negative symptoms,muscle stiffness,and motor restlessness.His Advanced Practice Nurse (APN)is considering changing the patient's antipsychotic medication,haloperidol (Haldol,a typical or first generation antipsychotic drug).For planning purposes,which medication can the nurse assume that the APN will probably choose?

Accepted Answer

Olanzapine is an atypical antipsychotic that produces few extrapyramidal side effects (EPS)and is effective in treating both positive and negative symptoms of schizophrenia.Chlorpromazine often produces EPS and is not effective in treating negative symptoms.Clozapine produces fewer EPS but would not be the drug of choice because of the danger of agranulocytosis.Fluoxetine is a selective serotonin reuptake inhibitor antidepressant.

Question 9

A patient with the diagnosis of schizophrenia,disorganized type,approaches the nurse and says,"It's beat,it's eat.No room for doom." The nurse can correctly assess this verbalization as:

Accepted Answer

Clanging,or clang associations,involves choosing words based on their sounds rather than their meanings and usually involves alliteration or rhyming.Neologisms are newly coined words.Looseness of association refers to thoughts that are poorly connected to each other,or that do not seem to present in logical order.Ideas of reference involve interpreting neutral events as somehow having specific meaning or relationship to the patient.

Question 10

A patient with schizophrenia has received typical (first-generation)antipsychotics for a year.His hallucinations are less intrusive,but he remains apathetic,has poverty of thought,cannot work,and is socially isolated.To address these symptoms,the nurse might consult the prescribing health care provider to suggest a change to:

Accepted Answer

Olanzapine is an atypical (second-generation)antipsychotic that targets both positive and negative symptoms of schizophrenia.Haldol and Thorazine are typical antipsychotics of the same class as the patient's present medication and are effective primarily on positive symptoms.Benadryl is an antihistamine and has no antipsychotic properties.

Question 11

A patient with schizophrenia begins to talk about creatures called "volmers" hiding in the warehouse where he works and undoing his work each night.The term "volmers" most likely represents:

Accepted Answer

A neologism is a newly coined word having special meaning to the patient."Volmer" is not a known word for an existing creature and given its context,most likely represents a new word created by the patient.Clanging (or clang associations)involves choosing words based on their sounds instead of their meanings,and is usually indicated by using words that somehow sound alike.Anhedonia is an inability to derive pleasure from pleasurable stimuli or activities,and alogia is a poverty or absence of speech.

Question 12

A patient standing in the dining room screams,"You are going to kill me!" He is very agitated and seems extremely frightened.He is mumbling to himself,and his eyes are darting as if tracking an unseen person.He then says repeatedly,"No! I can't! No!" Put the nursing interventions in the order they should be undertaken.
A) Send other staff to report the situation and obtain PRN medication.
B) Assure the patient that staff will make sure that everyone stays safe.
C) Clear the dining room of other patients and unnecessary personnel.
D) Explain that the medication will stop the voices,then administer it.

Accepted Answer

The answer of A patient standing in the dining room...

Question 13

A patient with schizophrenia tells the nurse "I don't know,it's just all the same.You never know.It comes,it goes,it blows away.Get it?" The best response for the nurse to make would be:

Accepted Answer

When a patient's speech is loosely associated,confused,and disorganized,it is important to inform that patient that you have not understood what he has said.This provides the patient with an opportunity to clarify and be assured that the nurse has understood him and will respond appropriately.Stating,"You are not making sense" places all responsibility for communication on the patient and suggests that the nurse believes the patient is defective;this would likely frustrate and distress the patient and reduce his self-esteem.Pretending to understand is nontherapeutic because it gives the patient the false impression that he is communicating effectively.Asking him to organize his thoughts is asking him to do something that is very difficult for him to do;his cognitive impairment is persistent and broad,not momentary or limited.

Question 14

A patient with schizophrenia tells the nurse,"Everyone must listen to me.I am the redeemer.I will bring peace to the world." From this the nurse can determine that an appropriate nursing diagnosis is:

Accepted Answer

The patient's grandiose delusion is based on reaction formation to actual feelings of low self-esteem;in other words,the grandiose delusion compensates for the patient's poor self-esteem.The scenario does not provide sufficient data to support the other diagnoses.

Question 15

The nurse spends several sessions with a patient with paranoid schizophrenia and the patient's family to help them understand the importance of antipsychotic medication in controlling his illness.The patient repeatedly states he isn't sick and the pills make him stiff,and family members say he doesn't think the medication helps him.They indicate that their efforts to promote adherence only lead to a hostile response from the patient.Which options should the nurse discuss with the patient's prescribing provider? Select all that apply.

Accepted Answer

Medications such as fluphenazine decanoate and haloperidol decanoate are long-acting forms of antipsychotic medication given by injection every 2 to 4 weeks,thus reducing the need for daily medications and struggles that may accompany these.The long-acting injections ensure that the patient maintains a therapeutic drug level,something unlikely when oral medications are taken intermittently.Discussing and addressing the patient's concerns about side effects (some of which can be extremely distressing)conveys interest in the patient and involves him in his treatment,and reducing side effects reduces resistance to the medication.Tying the medication to increasing the chance that the patient will meet his goals provides patient-centered motivation to take the medication (rather than taking it only at the behest of others).Adding a benzodiazepine would reduce anxiety,but that is not the likely cause of this patient's nonadherence.Telling the patient he will get sick without the medication is unlikely to help,because he does not believe he has an illness (anosognosia).

Question 16

Select the outcomes most appropriate for a patient in the third (maintenance)phase of treatment for schizophrenia."The patient will _________." Select all that apply.

Accepted Answer

The third or maintenance phase of schizophrenia treatment focuses maintaining achievements,preventing relapse,and achieving a satisfying quality of life.Behaviors associated with achievement of these objectives include maintaining a regular sleep pattern (prevents relapse),participating in support groups (prevents relapse),and expressing satisfaction with one's life (indicates satisfaction with quality of life).Achieving medication adherence is a focus of the second (stabilization)phase of treatment,and stabilizing a patient on his medications would be a focus of the first (acute)phase of treatment,which focuses on basic safety and medical stabilization.Using alcohol or caffeine in excess would increase the risk of relapse.

Question 17

A patient with schizophrenia has been stabilized in the Crisis Center and is about to be discharged.He will be living with his family,but the family knows nothing about the patient's illness,its treatment,or the role they can play in his recovery.Which activity would be most beneficial for the family to attend?

Accepted Answer

A psychoeducational group for caregivers explores the causes of schizophrenia,the role of medication and other treatments,promoting treatment adherence,what the caregivers can expect to see and how best to respond,and support for the ill member and caregivers.Such a group can be of immeasurable practical assistance to the family.The other types of therapy are designed to address dysfunction in the family unit or members of the family and do not focus on improving the family's understanding of the illness and how to manage it.

Question 18

A patient receiving risperidone (Risperdal)reports severe muscle stiffness midmorning.During lunch he has difficulty swallowing food and speaking,and when vital signs are taken 30 minutes later,he is noted to be stuporous and diaphoretic,with a temperature of 38.8° C,pulse of 110 beats/min,and blood pressure of 150/90 mm Hg.The nurse should suspect _________ and should ______________.

Accepted Answer

Neuroleptic malignant syndrome is a life-threatening reaction to antipsychotic medications that presents with increasing muscular stiffness (leading to rigidity),hyperpyrexia,autonomic nervous system instability,diminished level of consciousness,and other symptoms.Emergency cooling measures are indicated for hyperpyrexia,and because this is a dangerous medical emergency,care in a medical unit (preferably intensive care unit)is required stat.Anticholinergic toxicity includes hyperpyrexia and elevated and unstable vital signs but includes hot,dry skin and does not include motor rigidity.A simple relapse would not include the physical changes noted here.Agranulocytosis would present with symptoms suggesting infection,not the severe symptoms noted here.

Question 19

A patient with schizophrenia who admits to auditory hallucinations anxiously tells the nurse,"The voice is telling me to do things." Which of the following responses should the nurse make next?

Accepted Answer

Learning what a command hallucination is telling the patient to do is important because the command often places the patient or others at risk for harm.Command hallucinations can be terrifying and may pose a psychiatric emergency.The other queries are of lesser importance than identifying the command.

Question 20

A patient with schizophrenia who has received chlorpromazine (Thorazine)200 mg PO four times daily for 4 weeks has symptoms of a shuffling,propulsive gait,a masklike face,and drooling.Which nursing response would be most appropriate? Select all that apply.

Accepted Answer

Pseudoparkinsonism induced by antipsychotic medication mimics the symptoms of Parkinson's disease.It is not a side effect that one tends to adjust to;it tends to persist and can become marked.Appropriate responses include adjunctive antiparkinsonian medications such as benztropine (Cogentin),which should be given IM because of impaired swallowing ability (as evidenced by the patient's drooling).Addressing elements individually,as in instituting fall precautions owing to the impaired gait and suggesting wearing a towel so that the patient can frequently wipe accumulating drool and avert soiling his clothing,are also helpful.Administering PRN trihexyphenidyl (Artane)PO would be acceptable only if the patient did not exhibit impaired swallowing.Altering when or how the medication is administered would be helpful for issues such as sedation but not pseudoparkinsonism.Changes in motor activity seen in pseudoparkinsonism cannot be countered by increasing physical activity or trying to be more facially expressive.

Quiz 15: Schizophrenia

A patient is noted to be bending over backward in the group room.A peer asks what he is doing,and he replies,"People say they are bending over backwards to help me,so I am bending over backwards to help myself." This is an example of:

At 11:00 AM,a patient with schizophrenia who exhibits concrete thinking asks the nurse for PRN acetaminophen (Tylenol) .However,he last had it at 8:00 AM,and it is ordered only every 4 hours.Which nursing response would be most therapeutic?

The physician prescribes haloperidol (Haldol) ,a first-generation antipsychotic drug,for a patient with schizophrenia who displays delusions,hallucinations,apathy,and social isolation.Which symptoms should most be monitored to evaluate the expected improvement from this medication?

A patient with the diagnosis of schizophrenia,disorganized type,approaches the nurse and says,"It's beat,it's eat.No room for doom." The nurse can correctly assess this verbalization as:

A patient with schizophrenia begins to talk about creatures called "volmers" hiding in the warehouse where he works and undoing his work each night.The term "volmers" most likely represents:

A patient with schizophrenia tells the nurse "I don't know,it's just all the same.You never know.It comes,it goes,it blows away.Get it?" The best response for the nurse to make would be:

A patient with schizophrenia tells the nurse,"Everyone must listen to me.I am the redeemer.I will bring peace to the world." From this the nurse can determine that an appropriate nursing diagnosis is:

Select the outcomes most appropriate for a patient in the third (maintenance) phase of treatment for schizophrenia."The patient will _________." Select all that apply.

A patient with schizophrenia who admits to auditory hallucinations anxiously tells the nurse,"The voice is telling me to do things." Which of the following responses should the nurse make next?

A patient with schizophrenia who has received chlorpromazine (Thorazine) 200 mg PO four times daily for 4 weeks has symptoms of a shuffling,propulsive gait,a masklike face,and drooling.Which nursing response would be most appropriate? Select all that apply.