Nokea
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 are laughing. Tell me what's happening.
Correct Answer: D
Rationale: The patient is likely laughing in response to inner stimuli such as hallucinations or fantasy. Focusing on the hallucinatory clue (i.e., the patient's laughter) and then eliciting the patient's observation is best. 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 has said in the first place.
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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 says, 'Everyone has skin lice that jump on you and contaminate your blood.' Which problem is evident?
- A. Poverty of content
- B. Concrete thinking
- C. Neologisms
- D. Paranoia
Correct Answer: D
Rationale: The patient's unrealistic fear of contamination 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 says, 'My coworkers are out to get me. I also saw two doctors plotting to overdose me.' What term identifies how this patient is perceiving the environment?
- A. Disorganized
- B. Unpredictable
- C. Dangerous
- D. Bizarre
Correct Answer: C
Rationale: The patient sees the world as hostile and dangerous. This assessment is important because the nurse can be more effective by using empathy to respond to the patient. Data are not present to support any of the other options.
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 as what classic behavior?
- A. Echolalia
- B. An idea of reference
- C. A delusion of infidelity
- D. An auditory hallucination
Correct Answer: B
Rationale: Ideas of reference are misinterpretations of the verbalizations or actions of others that give special personal meanings to these behaviors; for example, when seeing two people talking, the individual assumes they are talking about him or her. The other terms do not correspond with the scenario.
When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol was prescribed. The patient now says, 'I stopped taking those pills. I didn't like how it made me feel.' What likely side effects did the patient experience?
- 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
Correct Answer: A
Rationale: Typical antipsychotic drugs often produce sedation and extrapyramidal side effects such as stiffness and gait disturbance. The side effects mentioned in the other options are usually not associated with typical antipsychotic therapy or would not have the effect described by the patient.