Nokea
A patient diagnosed with schizophrenia has auditory hallucinations. The patient anxiously tells the nurse, 'The voice is telling me to do things.' Select the nurse's priority assessment question.
- A. How long has the voice been directing your behavior?
- B. Do the messages from the voice frighten you?
- C. Do you recognize the voice speaking to you?
- D. What is the voice telling you to do?
Correct Answer: D
Rationale: Learning what a command hallucination is telling the patient to do is important; the command often places the patient or others at risk for harm. Command hallucinations can be terrifying and may pose a psychiatric emergency. The incorrect questions are of lesser importance than identifying the command.
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Patients diagnosed with schizophrenia who are suspicious and withdrawn generally present with what additional characteristic?
- A. Universally fear sexual involvement with therapists.
- B. Are socially disabled by the positive symptoms of schizophrenia.
- C. Exhibit a high degree of hostility as evidenced by rejecting behavior.
- D. Avoid relationships because they become anxious with emotional closeness.
Correct Answer: D
Rationale: When an individual is suspicious and distrustful and perceives the world and the people in it as potentially dangerous, withdrawal into an inner world can be a defense against uncomfortable levels of anxiety. When someone attempts to establish a relationship with such a patient, the patient's anxiety rises until trust is established. No evidence suggests that withdrawn patients with schizophrenia universally fear sexual involvement with therapists. In most cases, it is not considered true that withdrawn patients with schizophrenia are socially disabled by the positive symptoms of schizophrenia or exhibit a high degree of hostility by demonstrating rejecting behavior.
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.
A patient diagnosed with schizophrenia is acutely disturbed and violent. After several doses of haloperidol, the patient is calm. Two hours later the nurse sees the patient's head rotated to one side in a stiff position; the lower jaw is thrust forward, and the patient is drooling. Which effect is the patient demonstrating?
- A. Acute dystonic reaction
- B. Tardive dyskinesia
- C. Waxy flexibility
- D. Akathisia
Correct Answer: A
Rationale: Acute dystonic reactions involve painful contractions of the tongue, face, neck, and back; opisthotonos and oculogyric crisis may be observed. Dystonic reactions are considered emergencies that require immediate intervention. Tardive dyskinesia involves involuntary spasmodic muscular contractions that involve the tongue, fingers, toes, neck, trunk, or pelvis; it appears after prolonged treatment. Waxy flexibility is a symptom observed in catatonic schizophrenia. Akathisia is evidenced by internal and external restlessness, pacing, and fidgeting.
A patient diagnosed with schizophrenia is hospitalized after arguing with coworkers and threatening to harm them. The patient is aloof and suspicious and says, 'Two staff members I saw talking were plotting to assault me.' Based on data gathered at this point, which nursing diagnoses relate?
- A. Risk for other-directed violence
- B. Disturbed thought processes
- C. Risk for loneliness
- D. Spiritual distress
- E. Social isolation
Correct Answer: A,B
Rationale: Delusions of persecution and ideas of reference support the nursing diagnosis of disturbed thought processes. Risk for other-directed violence is substantiated by the patient's paranoia and feeling endangered by persecutors. Fearful individuals may strike out at perceived persecutors or attempt self-harm to get away from persecutors. Data are not present to support the other diagnoses.
A patient diagnosed with schizophrenia has taken a first-generation antipsychotic medication for a year. Hallucinations are less intrusive, but the patient continues to have apathy, poverty of thought, and social isolation. The nurse expects a change to which medication?
- A. Haloperidol
- B. Olanzapine
- C. Chlorpromazine
- D. Diphenhydramine
Correct Answer: B
Rationale: Olanzapine is an atypical antipsychotic medication that targets both positive and negative symptoms of schizophrenia. Haloperidol and chlorpromazine are first-generation (conventional) antipsychotic agents that target only positive symptoms. Diphenhydramine is an antihistamine.