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A newly admitted patient diagnosed with schizophrenia says, 'The voices are bothering me. They weigh 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 will stay with you. Focus on what we are talking about, not the voices.
- D. Forget about the voices. Ask some other patients to sit and talk with you.
Correct Answer: C
Rationale: 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. Asking other patients to talk incorrectly shifts responsibility for intervention from the nurse to other patients.
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A health care provider considers which antipsychotic medication to prescribe for a patient diagnosed with schizophrenia who has auditory hallucinations and poor social functioning. The patient is also overweight. Which drug should the nurse advocate?
- A. Clozapine
- B. Ziprasidone
- C. Olanzapine
- D. Aripiprazole
Correct Answer: D
Rationale: 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.
A nurse observes a 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
- B. Waxy flexibility
- C. Depersonalization
- D. Thought withdrawal
Correct Answer: B
Rationale: 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.
A patient diagnosed with schizophrenia demonstrates paranoid thinking. The patient angrily tells a nurse, 'You are mean and nasty. No one trusts you or wants to be around you.' What is the likely motivation behind this behavior?
- A. Attempting to manipulate the nurse by using negative comments
- B. The prelude to disorganization and catatonia in the near future
- C. Jealousy of the nurse's position of power in the relationship
- D. Identifying another person's shortcomings in order to preserve his or her own self-esteem
Correct Answer: D
Rationale: Patients with paranoid ideation often use disparaging comments to preserve their own self-esteem. There is no evidence the patient is trying to manipulate the nurse or is jealous. This behavior is not predictive of catatonia or disorganization.
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
Correct Answer: B
Rationale: 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.
A patient diagnosed with schizophrenia is stuporous, 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. voluntarily accept tube feeding by day 2.
Correct Answer: B
Rationale: 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.