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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.
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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 diagnosed with schizophrenia is demonstration catatonia. The patient has little spontaneous movement and waxy flexibility. Which patient needs are of priority importance?
- A. Psychosocial
- B. Physiological
- C. Self-actualization
- D. Safety and security
Correct Answer: B
Rationale: Physiological needs must be met to preserve life. A patient who is catatonic may need to be fed by hand or tube, toileted, and given range-of-motion exercises to preserve physiological integrity. The assessment findings do not suggest safety concerns. Higher-level needs (psychosocial and self-actualization) are of lesser concern.
A patient diagnosed with schizophrenia says, 'My coworkers are out to get me. I also saw two doctors plotting to overdose me.' What term identifies how this patient is perceiving the environment?
- A. Disorganized
- B. Unpredictable
- C. Dangerous
- D. Bizarre
Correct Answer: C
Rationale: The patient sees the world as hostile and dangerous. This assessment is important because the nurse can be more effective by using empathy to respond to the patient. Data are not present to support any of the other options.
A community mental health nurse wants to establish a relationship with a very withdrawn patient diagnosed with schizophrenia. The patient lives at home with a supportive family. Select the nurse's best plan.
- A. Visit daily for 4 days, then visit every other day for 1 week; stay with the patient for 20 minutes; accept silence; state when the nurse will return.
- B. Arrange to spend 1 hour each day with the patient; focus on asking questions about what the patient is thinking or experiencing; avoid silences.
- C. Visit twice daily; sit beside the patient with a hand on the patient's arm; leave if the patient does not respond within 10 minutes.
- D. Visit every other day; remind the patient of the nurse's identity; encourage the patient to talk while the nurse works on reports.
Correct Answer: A
Rationale: Severe constraints on the community mental health nurse's time will approximately not allow more time than what is mentioned in the correct option, yet important principles can be used. A severely withdrawn patient should be met 'at the patient's own level,' with silence accepted. Short periods of contact are helpful to minimize both the patient's and the nurse's anxiety. Predictability in returning as stated will help build trust. An hour may be too long to sustain a home visit with a withdrawn patient, especially if the nurse persists in leveling a barrage of questions at the patient. Twice-daily visits are probably not possible and leaving after 10 minutes would be premature. Touch may be threatening. Working on reports suggests the nurse is not interested in the patient.
An acutely violent patient diagnosed with schizophrenia receives several doses of haloperidol. Two hours later the nurse notices the patient's head rotated to one side in a stiffly fixed position; the lower jaw is thrust forward, and the patient is drooling. Which intervention by the nurse is indicated?
- A. Administer diphenhydramine 50 mg IM from the PRN medication administration record.
- B. Reassure the patient that the symptoms will subside. Practice relaxation exercises with the patient.
- C. Give trihexyphenidyl 5 mg orally at the next regularly scheduled medication administration time.
- D. Administer atropine sulfate 2 mg subcutaneously from the PRN medication administration record.
Correct Answer: A
Rationale: Diphenhydramine, trihexyphenidyl, benztropine, and other anticholinergic medications may be used to treat dystonias. Swallowing will be difficult or impossible; therefore, oral medication is not an option. Medication should be administered immediately; therefore, the intramuscular route is best. In this case, the best option given is diphenhydramine.