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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.
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A person diagnosed with schizophrenia has had difficulty keeping a job because of severe paranoia. Today the person shouts, 'They're all plotting to destroy me.' Select the nurse's most therapeutic response.
- A. Everyone here is trying to help you. No one wants to harm you.
- B. Feeling that people want to destroy you must be very frightening.
- C. That is not true. People here are trying to help if you will let them.
- D. Staff members are health care professionals who are qualified to help you.
Correct Answer: B
Rationale: Resist focusing on content; instead, focus on the feelings the patient is expressing. This strategy prevents arguing about the reality of delusional beliefs. Such arguments increase patient anxiety and the tenacity with which the patient holds to the delusion. The other options focus on content and provide opportunity for argument.
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 nurse works with a patient diagnosed with schizophrenia regarding the importance of medication management. The patient repeatedly says, 'I don't like taking pills.' Which treatment strategy should the nurse discuss with the patient and health care provider?
- A. Use of long-acting antipsychotic injections
- B. Addition of a benzodiazepine, such as lorazepam
- C. Adjunctive use of an antidepressant, such as amitriptyline
- D. Inpatient hospitalization because of the high risk for exacerbation of symptoms
Correct Answer: A
Rationale: Medications such as paliperidone, fluphenazine decanoate, and haloperidol decanoate are long-acting forms of antipsychotic medications. They are administered by depot injection every 2 to 4 weeks, thus reducing daily opportunities for nonadherence. The incorrect options do not address the patient's dislike of taking pills.
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 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.