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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.
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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.
What assessment findings mark the prod sall prodromal stage of schizophrenia?
- A. Withdrawal, magical thinking, poor concentration, and perceptual disturbances
- B. Auditory hallucinations, ideas of reference, thought insertion, and broadcasting
- C. Stereotyped behavior, echopraxia, echolalia, and waxy flexibility
- D. Loose associations, concrete thinking, and echolalia neologisms
Correct Answer: A
Rationale: Early prodromal symptoms include social withdrawal and deterioration in functioning, depressive mood, perceptual disturbances, magical thinking, and peculiar behavior. Changes in self-care, sleeping or eating patterns, and changes in school or work performance may also be evidenced. The incorrect options each list the positive symptoms of schizophrenia that are more likely to be apparent during the acute stage of the illness.
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.
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.
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.