Nokea
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.
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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 nurse observes a patient standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon?
- A. Echolalia
- B. Waxy flexibility
- C. Depersonalization
- D. Thought withdrawal
Correct Answer: B
Rationale: Waxy flexibility is the ability to hold distorted postures for extended periods, as though the patient were molded in wax. Echolalia is a speech pattern. Depersonalization refers to a feeling state. Thought withdrawal refers to an alteration in thinking.
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.
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 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.