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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.
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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 receiving risperidone reports severe muscle stiffness at 10:30 am. By noon, the patient is diaphoretic, drooling, and has difficulty swallowing. By 4:00 pm, vital signs are body temperature, 102.8°F; pulse, 110 beats/min; respirations, 26 breaths per minute; and blood pressure, 150/90 mm Hg. Select the nurse's best analysis and action.
- A. Agranulocytosis. Institute reverse isolation.
- B. Tardive dyskinesia. Withhold the next dose of medication.
- C. Cholestatic jaundice. Begin a high-protein, low-fat diet.
- D. Neuroleptic malignant syndrome. Immediately notify the health care provider.
Correct Answer: D
Rationale: Taking an antipsychotic medication coupled with the presence of extrapyramidal symptoms, such as severe muscle stiffness and difficulty swallowing, hyperpyrexia, and autonomic symptoms (pulse elevation), suggest neuroleptic malignant syndrome, a medical emergency. The symptoms given in this scenario are not consistent with the medical problems listed in the incorrect options.
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 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 health care provider considers which antipsychotic medication to prescribe for a patient diagnosed with schizophrenia who has auditory hallucinations and poor social functioning. The patient is also overweight. Which drug should the nurse advocate?
- A. Clozapine
- B. Ziprasidone
- C. Olanzapine
- D. Aripiprazole
Correct Answer: D
Rationale: Aripiprazole is an atypical antipsychotic medication that is effective against both positive and negative symptoms of schizophrenia. It causes little or no weight gain and no increase in glucose, high- or low-density lipoprotein cholesterol levels, or triglycerides, making it a reasonable choice for a patient with obesity or heart disease. Clozapine may produce agranulocytosis, making it a poor choice as a first-line agent. Ziprasidone may prolong the QT interval, making it a poor choice for a patient with cardiac disease. Olanzapine fosters weight gain.