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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.
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A person diagnosed with schizophrenia has had difficulty keeping a job because of severe paranoia. Today the person shouts, 'They're all plotting to destroy me.' 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 if you will let them.
- D. Staff members are health care professionals who are qualified to help you.
Correct Answer: B
Rationale: 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.
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.
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, 'Demons are in the basement and they can come through the floor.' The nurse can correctly assess this information as what?
- A. Need for psychoeducation
- B. Medication nonadherence
- C. Chronic deterioration
- D. Relapse
Correct Answer: D
Rationale: 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 regularly taking his or her medication. Psychoeducation is more effective when the patient's symptoms are stable. Chronic deterioration is not the best explanation.
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.
The family of a patient diagnosed with schizophrenia is unfamiliar with the illness and their role in recovery. Which type of therapy should the nurse recommend?
- A. Psychoeducational
- B. Psychoanalytic
- C. Transactional
- D. Family
Correct Answer: A
Rationale: A psychoeducational group explores the causes of schizophrenia, the role of medications, the significance of medication compliance, and the importance of support for the ill member of the family, and also provides recommendations for living with a person with schizophrenia. Such a group can be of practical assistance to the family members. The other types of therapy do not focus on psychoeducation.