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The nurse is told that a patient with disorganized schizophrenia is being admitted to the unit. The nurse should expect the patient to demonstrate:
- A. highly suspicious, delusional behavior.
- B. extremes of motor activity and excitement to stupor.
- C. social withdrawal and ineffective communication.
- D. severe anxiety and ritualistic behavior.
Correct Answer: C
Rationale: The correct answer is C because disorganized schizophrenia is characterized by social withdrawal and ineffective communication. This subtype of schizophrenia involves disorganized speech and behavior, flat or inappropriate affect, and disorganized thinking. Patients with this type may display bizarre or nonsensical behavior and have difficulty with daily activities. Choice A is incorrect as suspiciousness and delusions are more commonly associated with paranoid schizophrenia. Choice B is incorrect as extremes of motor activity and excitement to stupor are characteristic of catatonic schizophrenia. Choice D is incorrect as severe anxiety and ritualistic behavior are not typical features of disorganized schizophrenia.
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When analyzing the behaviors of a 23-year-old who meets the criteria for antisocial personality disorder, the nurse recognizes that the following nursing diagnosis would be pertinent to his care:
- A. Risk for self-mutilation
- B. Disturbed personal identity
- C. Impaired social interaction
- D. Social isolation
Correct Answer: C
Rationale: Step-by-step rationale for choice C (Impaired social interaction) being the correct answer:
1. Antisocial personality disorder is characterized by a lack of regard for others and a pattern of violating their rights.
2. Individuals with this disorder often have difficulty forming and maintaining healthy relationships.
3. Impaired social interaction reflects the challenges the individual faces in relating to others.
4. This nursing diagnosis would address the core issue of social dysfunction in individuals with antisocial personality disorder.
Summary of why the other choices are incorrect:
A. Risk for self-mutilation - Not typically associated with antisocial personality disorder, more common in other mental health conditions.
B. Disturbed personal identity - Not a primary concern in antisocial personality disorder, which is more about behavior than identity.
D. Social isolation - While individuals with antisocial personality disorder may isolate themselves, impaired social interaction is a more direct and specific issue to address in their care.
A newly admitted patient diagnosed with paranoid schizophrenia is hypervigilant and constantly scans the environment. He states that he saw two doctors talking in the hall and knows they were plotting to kill him. When charting, how should the nurse identify this behavior?
- A. Idea of reference
- B. Delusion of infidelity
- C. Auditory hallucination
- D. Echolalia
Correct Answer: A
Rationale: The correct identification for the behavior described is "A: Idea of reference." This term refers to the belief that neutral events are directed at oneself. In this case, the patient's belief that the doctors were plotting to kill him is an example of a false idea of reference. Delusion of infidelity (choice B) involves false beliefs about a partner's unfaithfulness, not relevant here. Auditory hallucination (choice C) pertains to false perceptions of hearing sounds, not applicable. Echolalia (choice D) is the repetition of words spoken by others, not seen in this scenario. Identifying the behavior as an idea of reference helps the nurse understand the patient's distorted perception of reality.
An unusual state called 'waxy flexibility' is sometimes observed in schizophrenia
- A. borderline
- B. disorganized
- C. catatonic
- D. paranoid
Correct Answer: C
Rationale: Waxy flexibility, a motor symptom, is unique to catatonic schizophrenia.
Statistical approaches to abnormality define as 'abnormal' those who
- A. show evidence of loss of contact with reality
- B. are unhappy, withdrawn, and depressed
- C. deviate from typical or average patterns of behavior
- D. are disabled by anxiety
Correct Answer: C
Rationale: Statistical definitions label behavior abnormal if it deviates significantly from the norm, regardless of specific symptoms.
A client who has been diagnosed as having paranoid schizophrenia is highly suspicious and delusional. He hears voices telling him terrorists are plotting to assassinate him. He refuses to eat, saying the food is poisoned. The nursing action that best addresses his needs is to:
- A. Explain that others eat the food and are not harmed
- B. Allow client to select food from vending machines
- C. Assist client with personal hygiene and grooming
- D. Not allow client to verbalize delusional thoughts
Correct Answer: B
Rationale: The correct answer is B: Allow client to select food from vending machines. This option respects the client's autonomy and addresses his specific delusion of food being poisoned. By allowing the client to select food from vending machines, he can choose items he believes are safe, which can help alleviate his paranoia and increase his trust in the care being provided. This approach promotes a therapeutic relationship and empowers the client in making choices about his care.
Explanation of why other choices are incorrect:
A: Explaining that others eat the food and are not harmed may not be effective as the client's delusion is strong, and rational arguments may not be helpful in this case.
C: Assisting with personal hygiene and grooming is important but does not directly address the client's delusion about food being poisoned.
D: Not allowing the client to verbalize delusional thoughts can escalate the client's distress and hinder the therapeutic relationship. It is essential to acknowledge the client's experiences and work towards building trust and rapport