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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.
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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 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 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.
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 says, 'High heat. Last time here. Did you get a coat?' What type of verbalization is evident?
- A. Neologism
- B. Idea of reference
- C. Thought broadcasting
- D. Associative looseness
Correct Answer: D
Rationale: Looseness of association refers to jumbled thoughts incoherently expressed to the listener. Neologisms are newly coined words. Ideas of reference are a type of delusion. Thought broadcasting is the belief that others can hear one's thoughts.