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A patient diagnosed with schizophrenia has auditory hallucinations, delusions of grandeur, poor personal hygiene, and motor agitation. Which assessment finding would the nurse regard as a negative symptom of schizophrenia?
- A. Auditory hallucinations
- B. Delusions of grandeur
- C. Poor personal hygiene
- D. Motor agitation
Correct Answer: C
Rationale: Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning. The distractors are positive symptoms of schizophrenia.
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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 anxiously says, 'I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror.' What phenomena is the patient describing?
- A. Derealization
- B. Concrete thinking
- C. Abstract thinking
- D. Depersonalization
Correct Answer: D
Rationale: Depersonalization: a nonspecific feeling of having lost one's identity; the self is different or unreal. People may be concerned that body parts do not belong to them, or they may have an acute sensation that the body has drastically changed. Derealization is the false perception that the environment has changed. Concrete thinking refers to an overemphasis on specific details and a literal interpretation of ideas. It is contrasted with abstract thinking. People who think in an abstract way look at the broader significance of ideas and information rather than the concrete details.
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 community mental health nurse wants to establish a relationship with a very withdrawn patient diagnosed with schizophrenia. The patient lives at home with a supportive family. Select the nurse's best plan.
- A. Visit daily for 4 days, then visit every other day for 1 week; stay with the patient for 20 minutes; accept silence; state when the nurse will return.
- B. Arrange to spend 1 hour each day with the patient; focus on asking questions about what the patient is thinking or experiencing; avoid silences.
- C. Visit twice daily; sit beside the patient with a hand on the patient's arm; leave if the patient does not respond within 10 minutes.
- D. Visit every other day; remind the patient of the nurse's identity; encourage the patient to talk while the nurse works on reports.
Correct Answer: A
Rationale: Severe constraints on the community mental health nurse's time will approximately not allow more time than what is mentioned in the correct option, yet important principles can be used. A severely withdrawn patient should be met 'at the patient's own level,' with silence accepted. Short periods of contact are helpful to minimize both the patient's and the nurse's anxiety. Predictability in returning as stated will help build trust. An hour may be too long to sustain a home visit with a withdrawn patient, especially if the nurse persists in leveling a barrage of questions at the patient. Twice-daily visits are probably not possible and leaving after 10 minutes would be premature. Touch may be threatening. Working on reports suggests the nurse is not interested in the patient.
A patient presenting with delusions of persecution about being poisoned has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the patient?
- A. Allow the patient to have supervised access to food vending machines.
- B. Allow the patient to telephone a local restaurant to deliver meals.
- C. Offer to taste each portion on the tray for the patient.
- D. Begin tube feedings or total parenteral nutrition.
Correct Answer: A
Rationale: The patient who is delusional about food being poisoned is likely to believe restaurant food might still be poisoned and to say that the staff member tasting the food has taken an antidote to the poison before tasting. Attempts to tube feed or give nutrition intravenously are considered aggressive and usually promote violence. Patients often perceive foods in sealed containers, packages, or natural shells as being safe.