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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.
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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 tells the nurse, 'I eat skiller. Tend to end. Easter. It blows away. Get it?' Select the nurse's best response.
- A. Nothing you are saying is clear.
- B. Your thoughts are very disconnected.
- C. Try to organize your thoughts, and then tell me again.
- D. I am having difficulty understanding what you are saying.
Correct Answer: D
Rationale: When a patient's speech is loosely associated, confused, and disorganized, pretending to understand is useless. The nurse should tell the patient that he or she is having difficulty understanding what the patient is saying. If a theme is discernible, ask the patient to talk about the theme. The incorrect options tend to place blame for the poor communication with the patient. The correct response places the difficulty with the nurse rather than being accusatory.
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.
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 begins a new prescription for lurasidone HCl. The patient is 5 feet 6 inches tall and currently weighs 204 pounds. Which topic is most important for the nurse to include in the teaching plan related to this medication?
- A. How to recognize tardive dyskinesia?
- B. Weight management strategies.
- C. Ways to manage constipation.
- D. Sleep hygiene measures.
Correct Answer: B
Rationale: Lurasidone HCl (Latuda) is an atypical antipsychotic medication. The incidence of weight gain, diabetes, and high cholesterol is high with this medication. The patient is overweight now, so weight management is especially important. The incidence of tardive dyskinesia is low with atypical antipsychotic medications. Constipation may occur, but it is less important than weight management. This drug usually produces drowsiness.