ch 34 Flashcards
A patient previously diagnosed as psychotic expresses to the nurse that he is seeing spiders climbing up the walls in his room and he is concerned that they will get into his bed. What is the nurse’s best response?
a. Ignore his remarks and remain silent when providing care.
b. Express doubt that there are spiders on the wall.
c. Ask the patient if he also sees spiders in the day room.
d. Tell the patient there are no spiders and he should stop worrying about it.
ANS: B
The patient is experiencing visual hallucinations. Appropriate care for this patient would not include reinforcing his hallucinations, being dismissive of him, or ignoring him. Expressing reasonable doubt is the correct answer.
A patient with schizophrenia is admitted to the inpatient unit. Which behavior should the nurse expect to see that is most likely to be associated with this disorder?
a. Wringing of hands
b. Monotone speech pattern
c. Engaged in conversations
d. Presence of hallucinations
ANS: D
Individuals who have a clinical diagnosis of schizophrenia present with positive (delusions, hallucinations, disorganized speech and behavior, catatonia, and agitation) as well as negative symptoms (alogia, affective blunting, asocial behavior, anhedonia, and avolition) which distances the patient from society.
The nurse is planning discharge teaching for a patient taking clozapine. Which information is critical to include in the teaching plan?
a. Caution about sunlight exposure
b. Reminder to call the clinic if fever, sore throat, or malaise develops
c. Instructions regarding dietary restrictions
d. A chart to record patient weight
ANS: B
Fever, sore throat, and malaise are symptoms of agranulocytosis, a serious side effect of taking clozapine. Weekly blood counts are necessary to monitor for the condition. Sunlight exposure is a risk for persons taking chlorpromazine hydrochloride (Thorazine). There are no dietary restrictions for persons taking clozapine. While weight gain may occur when taking antipsychotic medication, daily monitoring is not required.
Which side effect is the highest priority for the nurse to assess for when diphenhydramine is administered to a patient also taking antipsychotic medication?
a. Increased psychosis
b. Cognitive impairment
c. Respiratory depression
d. Impaired memory
ANS: C
Diphenhydramine is an anticholinergic medication that may induce drowsiness or even respiratory depression taken along with anti-psychotic medication. Respiratory depression and airway are always highest priorities of care. While increased psychosis may occur, respiratory depression is highest priority. Cognitive impairment and impaired memory are not well-known effects of diphenhydramine.
A 23-year-old male veteran of the war in Iraq is admitted with a diagnosis of posttraumatic stress disorder (PTSD) following his arrest for destroying his girlfriend’s apartment. This is not his first angry outburst resulting in destruction of property. Which interventions by the nurse will be most helpful to this patient? (Select all that apply.)
a. Allow opportunities for him to express his anger.
b. Provide patient and family teaching regarding PTSD.
c. Tell the patient that hurting himself will solve nothing.
d. Report him to the authorities.
e. Exhibit a nonjudgmental attitude.
f. Reassure him that everything will be all right.
ANS: A, B, E
Allowing appropriate opportunities for him to express his anger will help him learn how to control his emotions or express them in a socially acceptable manner. Providing education to the patient and family will help them learn why he behaves the way he does and how to prevent or redirect his anger. Options C, D, and F are nontherapeutic in that they undermine the nurse–patient relationship. Being nonjudgmental in interactions with patients is a basic tenet of developing a therapeutic relationship.
In discussing disease prevention with a 15-year-old boy and his mother, the nurse identifies which of the following as risk factors for psychosis? (Select all that apply.)
a. Father diagnosed with paranoid schizophrenia
b. Rural residence
c. Recent immigration from Ecuador
d. Occasional cannabis use
e. January birth date
f. Physical abuse by the father
ANS: A, C, E, F
Genetic predisposition has been identified as a risk factor for development of schizophrenia. Immigration, winter birth, and family difficulties such as abuse have also been identified as risk factors. Urban residence, not rural, and chronic cannabis use, not occasional, have also been identified.
Patients who are psychotic because of underlying psychiatric illness are treated with antipsychotic medications. Typical antipsychotic medications can improve positive symptoms in patients with schizophrenia. Positive symptoms include which of the following? (Select all that apply.)
a. Hallucinations
b. Disorganized speech and behavior
c. Anhedonia
d. Delusions
e. Agitation
ANS: A, D, E
Positive symptoms of schizophrenia include the distortion or exaggeration of normal behavior, such as when the patient experiences hallucinations, delusions, or agitation. Negative symptoms are those that cause a loss of normal function, such as when the patient exhibits disorganized speech and behavior and anhedonia.
