Chapter 16: Schizophrenia Spectrum and Other Psychotic Disorders

Question 1

A person has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today the person shouts, “They’re all plotting to destroy me. Isn’t that true?” 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 you if you will let them.”
d. “Staff members are health care providers who are qualified to help you.”

Answer 1

ANS - B

Question 2

A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The patient states, “I saw two doctors talking in the hall. They were plotting to kill me.” The nurse may correctly assess this behaviour as which of the following?

a. Echolalia
b. An idea of reference
c. A delusion of infidelity
d. An auditory hallucination

Answer 2

ANS - B

Question 3

A patient diagnosed with schizophrenia says, “My co-workers are out to get me. I also saw two doctors plotting to kill me.” How does this patient perceive the environment?

a. Disorganized
b. Dangerous
c. Supportive
d. Bizarre

Answer 3

ANS - B

Question 4

When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol (Haldol) was prescribed. The patient now says, “I stopped taking those pills. They made me feel like a robot.” What are common side effects the nurse should validate with the patient?

a. Sedation and muscle stiffness
b. Sweating, nausea, and diarrhea
c. Mild fever, sore throat, and skin rash
d. Headache, watery eyes, and runny nose

Answer 4

ANS - A

Question 5

Which of the following patient statements implies a hallucination that requires the nurse to implement safety measures?

a. “I hear angels playing harps.”
b. “The voices say everyone is trying to kill me.”
c. “My dead father tells me I am a good person.”
d. “The voices talk only at night when I’m trying to sleep.”

Answer 5

ANS - B

Question 6

A patient’s care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating?

a. Detachment and overconfidence
b. Darting eyes, tilted head, mumbling to self
c. Euphoric mood, hyperactivity, distractibility
d. Foot tapping and repeatedly writing the same phrase

Answer 6

ANS - B

Question 7

A health care provider considers which antipsychotic medication to prescribe for a patient diagnosed with schizophrenia who has auditory hallucinations and poor social function. The patient is also overweight and hypertensive. Which drug should the nurse advocate?

a. Clozapine (Clozaril)
b. Ziprasidone (Zeldox)
c. Olanzapine (Zyprexa)
d. Aripiprazole (Abilify)

Answer 7

ANS - D

Question 8

A patient diagnosed with schizophrenia tells the nurse, “I eat skiller. Tend to end. Easter. It blows away. Get it?” Select the nurse’s best response.

a. “Nothing you are saying is clear.”
b. “Your thoughts are very disconnected.”
c. “Try to organize your thoughts and then tell me again.”
d. “I am having difficulty understanding what you are saying.”

Answer 8

D
When a patient’s speech is loosely associated, confused, and disorganized, pretending to understand is useless. The nurse should tell the patient that he or she is having difficulty understanding what the patient is saying. Clear messages and honesty are a vital part of working effectively in psychiatric mental health nursing. An honest response lets the person know that the nurse does not understand, would like to understand, and can be trusted to be honest. If a theme is discernible, ask the patient to talk about the theme. The incorrect options tend to place blame for the poor communication with the patient. The correct response places the difficulty with the nurse rather than being accusatory

Question 9

A patient diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which patient needs are of priority importance?

a. Self-esteem
b. Psychosocial
c. Physiological
d. Self-actualization

Answer 9

ANS: C
Physiological needs must be met to preserve life. A patient with waxy flexibility must be fed by hand or tube, toileted, given range-of-motion exercises, and so forth to preserve physiological integrity. Higher level needs are of lesser concern.

Question 10

A patient diagnosed with schizophrenia demonstrates little spontaneous movement and has waxy flexibility. The patient’s activities of daily living are severely compromised. An appropriate outcome would be which of the following?

a. The patient demonstrates increased interest in the environment by the end of week 1.
b. The patient performs self-care activities with coaching by the end of day 3.
c. The patient gradually takes the initiative for self-care by the end of week 2.
d. The patient accepts tube feeding without objection by day 2.

Answer 10

ANS: B
Outcomes related to self-care deficit nursing diagnoses should deal with increasing ability to perform self-care tasks independently, such as feeding, bathing, dressing, and toileting. Performing the tasks with coaching by nursing staff denotes improvement over the complete inability to perform the tasks. The incorrect options are not directly related to self-care activities, difficult to measure, or describe total care versus maintenance of self-care.

Question 11

A nurse observes a catatonic patient standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon?

a. Echolalia
b. Waxy flexibility
c. Depersonalization
d. Thought withdrawal

Answer 11

ANS: B
Waxy flexibility is the ability to hold distorted postures for extended periods of time, as though the patient were molded in wax. Echolalia is a speech pattern. Depersonalization refers to a feeling state. Thought withdrawal refers to an alteration in thinking.

Question 12

A patient is experiencing delusions of persecution about being poisoned. The patient has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the patient?

a. Allowing the patient supervised access to food vending machines
b. Allowing the patient to phone a local restaurant to deliver meals
c. Offering to taste each portion on the tray for the patient
d. Providing tube feedings or total parenteral nutrition

Answer 12

ANS: A
The patient who is delusional about food being poisoned is likely to believe restaurant food might still be poisoned and to say that the staff member tasting the food has taken an antidote to the poison before tasting. Attempts to tube feed or give nutrition intravenously are seen as aggressive and usually promote violence. Patients perceive foods in sealed containers, packages, or natural shells as being safer.

Question 13

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 every other day for 1 week; stay with 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.

Answer 13

ANS: A

Severe constraints on the community mental health nurse’s time will probably 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 levelling 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.

Question 14

Which of the following is true for withdrawn patients diagnosed with schizophrenia?

a. They are usually violent toward caregivers.
b. They universally fear sexual involvement with therapists.
c. They exhibit a high degree of hostility as evidenced by rejecting behaviour.
d. They avoid relationships because they become anxious with emotional closeness.

Answer 14

ANS: D
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 defence 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. There is no evidence that withdrawn patients with schizophrenia universally fear sexual involvement with therapists. In most cases, it is untrue that withdrawn patients with schizophrenia are commonly violent or exhibit a high degree of hostility by demonstrating rejecting behaviour.

Question 15

15. A newly admitted patient diagnosed with schizophrenia says, “The voices are bothering me. They yell and tell me I am 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’ll stay with you. Focus on what we are talking about, not the voices. ”
    d. “Forget the voices and ask some other patients to play cards with you.”

Answer 15

ANS: C
Staying with a distraught patient who is hearing voices serves several purposes: ongoing observation, the opportunity to provide reality orientation, a means of helping to 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. Suggesting playing cards with other patients shifts responsibility for intervention from the nurse to the patient and other patients.

Question 16

A patient diagnosed with schizophrenia has taken fluphenazine (Modecate) 5 mg po bid for 3 weeks. The nurse now observes a shuffling propulsive gait, a masklike face, and drooling. Which term applies to these symptoms?

a. Neuroleptic malignant syndrome
b. Hepatocellular effects
c. Pseudoparkinsonism
d. Akathisia

Answer 16

ANS - C

Pseudoparkinsonism induced by antipsychotic medication mimics the symptoms of Parkinson’s disease. It frequently appears within the first month of treatment and is more common with first-generation antipsychotic drugs. Hepatocellular effects would produce abnormal liver test results. Neuroleptic malignant syndrome is characterized by autonomic instability. Akathisia produces motor restlessness.

Question 17

A patient diagnosed with schizophrenia is very disturbed and violent. After several doses of haloperidol (Haldol), the patient is calm. Two hours later the nurse sees the patient’s head rotated to one side in a stiff position, the lower jaw thrust forward, and drooling. Which problem is most likely?

a. An acute dystonic reaction
b. Tardive dyskinesia
c. Waxy flexibility
d. Akathisia

Answer 17

ANS: A
Acute dystonic reactions involve painful contractions of the tongue, face, neck, and back. Opisthotonos and oculogyric crisis may be observed. Dystonic reactions are considered emergencies requiring immediate intervention. Tardive dyskinesia involves involuntary spasmodic muscular contractions that involve the tongue, fingers, toes, neck, trunk, or pelvis. It appears after prolonged treatment. Waxy flexibility is a symptom seen in catatonic schizophrenia. Internal and external restlessness, pacing, and fidgeting are characteristics of akathisia.

Question 18

An acutely violent patient diagnosed with schizophrenia receives several doses of haloperidol (Haldol). Two hours later, the nurse notices the patient’s head rotated to one side in a stiffly fixed position, the lower jaw thrust forward, and drooling. Which intervention by the nurse is indicated?

a. Administer diphenhydramine (Benadryl) 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 (Artane) 5 mg orally at the next regularly scheduled medication administration time.
d. Administer atropine sulfate 2 mg subcut from the prn medication administration record.

Answer 18

ANS: A
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, so the intramuscular route is best. In this case, the best option given is diphenhydramine.

Question 19

A patient took trifluoperazine 30 mg po daily for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patient’s neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect?

a. Agranulocytosis
b. Tardive dyskinesia
c. Tourette’s syndrome
d. Anticholinergic effects

Answer 19

ANS - B

Tardive dyskinesia is a neuroleptic-induced condition involving the face, trunk, and limbs. Involuntary movements, such as tongue thrusting; licking; blowing; irregular movements of the arms, neck, and shoulders; rocking; hip jerks; and pelvic thrusts are seen. These symptoms are frequently not reversible even when the drug is discontinued. The scenario does not present evidence consistent with the other disorders mentioned: agranulocytosis is a blood disorder; Tourette’s syndrome is a condition in which tics are present; and anticholinergic effects include dry mouth, blurred vision, flushing, constipation, and dry eyes

Question 20

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’re laughing. Tell me what’s happening.”

Answer 20

D
The patient is likely laughing in response to inner stimuli, such as hallucinations or fantasy. Focus on the hallucinatory clue (the patient’s laughter) and then elicit the patient’s observation. 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 said in the first place.

Question 21

The nurse assesses a patient diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia?

a. Auditory hallucinations
b. Delusions of grandeur
c. Poor personal hygiene
d. Psychomotor agitation

Answer 21

ANS: C
Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning. The distracters are positive symptoms of schizophrenia.

Question 22

What assessment findings mark the prodromal stage of schizophrenia?

a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion
b. Auditory hallucinations, ideas of reference, thought insertion, and broadcasting
c. Stereotyped behaviour, echopraxia, echolalia, and waxy flexibility
d. Loose associations, concrete thinking, and echolalia neologisms

Answer 22

ANS - A

Withdrawal, misinterpreting, poor concentration, and preoccupation with religion are prodromal symptoms, the symptoms that are present before the development of florid symptoms. The incorrect options list the positive symptoms of schizophrenia that might be apparent during the acute stage of the illness.

Question 23

A patient diagnosed with schizophrenia says, “Contagious bacteria are everywhere. When they get in your body, you will be locked up with other infected people.” Which problem is evident?

a. Poverty of content
b. Concrete thinking
c. Neologisms
d. Paranoia

Answer 23

ANS -D

The patient’s unrealistic fear of harm indicates paranoia. Neologisms are invented words. Concrete thinking involves literal interpretation. Poverty of content refers to an inadequate fund of information.

Question 24

A patient diagnosed with schizophrenia begins a new prescription for lurasidone (Latuda). The patient is 168 cm and currently weighs 95 kg. Which topic is most important for the nurse to include in the teaching plan related to this medication?

a. How to recognize tardive dyskinesia
b. Weight management strategies
c. Ways to manage constipation
d. Sleep hygiene measures

Answer 24

ANS - B

Lurasidone HCL (Latuda) is a second-generation antipsychotic medication. The incidence of weight gain, diabetes, and high cholesterol is high with this medication. The patient is overweight now, so weight management will be especially important. The incidence of tardive dyskinesia is low with second-generation antipsychotic medications. Constipation may occur, but it is less important than weight management. This drug usually produces drowsiness.

Question 25

A patient diagnosed with schizophrenia says, “It’s beat. Time to eat. No room for the cat.” What type of verbalization is evident?

a. Neologism
b. Idea of reference
c. Thought broadcasting
d. Associative looseness

Answer 25

ANS -D

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.

Question 26

A patient diagnosed with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive, but the patient continues to have apathy, poverty of thought, and social isolation. The nurse would expect a change to which medication?

a. Haloperidol (Haldol)
b. Olanzapine (Zyprexa)
c. Chlorpromazine (Thorazine)
d. Diphenhydramine (Benadryl)

Answer 26

ANS - B

Olanzapine is a second-generation atypical antipsychotic that targets both positive and negative symptoms of schizophrenia. Haloperidol and chlorpromazine are conventional antipsychotics that target only positive symptoms. Diphenhydramine is an antihistamine.
See relationship to audience response question.

Question 27

The family of a patient diagnosed with schizophrenia is unfamiliar with the illness and family’s role in recovery. Which type of therapy should the nurse recommend?

a. Psychoeducational
b. Psychoanalytic
c. Transactional
d. Family

Answer 27

ANS - A

A psychoeducational group explores the causes of schizophrenia, the role of medication, the importance of medication compliance, support for the ill member, and hints for living with a person with schizophrenia. Such a group can be of immeasurable practical assistance to the family. The other types of therapy do not focus on psychoeducation.

Question 28

A patient diagnosed with schizophrenia has been stable for a year; however, the family now reports the patient is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The patient says, “My computer is sending out infected radiation beams.” The nurse assesses this information as an indication of which of the following?

a. The need for psychoeducation
b. Medication noncompliance
c. Chronic deterioration
d. Relapse

Answer 28

ANS: D
Signs of potential relapse include feeling tense, difficulty concentrating, trouble sleeping, increased withdrawal, and increased bizarre or magical thinking. Medication noncompliance may not be implicated. Relapse can occur even when the patient is taking medication regularly. Psychoeducation is more effective when the patient’s symptoms are stable. Chronic deterioration is not the best explanation.

Question 29

A patient diagnosed with schizophrenia begins to talks about “macnabs” hiding in the warehouse at work. The term macnabs should be documented as which of the following?

a. A neologism
b. Concrete thinking
c. Thought insertion
d. An idea of reference

Answer 29

ANS: A
A neologism is a newly coined word having special meaning to the patient. Macnabs is not a known common word. Concrete thinking refers to the inability to think abstractly. Thought insertion refers to the belief that the thoughts of others are implanted in one’s mind. Ideas of reference are a type of delusion in which trivial events are given personal significance.

Question 30

A patient diagnosed with schizophrenia anxiously says, “I can see the left side of my body merging with the wall. Then my face appears and disappears in the mirror.” While listening, the nurse should do which of the following?

a. Sit close to the patient
b. Place an arm protectively around the patient’s shoulders
c. Place a hand on the patient’s arm and exert light pressure
d. Maintain a normal social interaction distance from the patient

Answer 30

ANS: D
The patient is describing phenomena that indicate personal boundary difficulties and depersonalization. The nurse should maintain appropriate social distance and not touch the patient because the patient is anxious about the inability to maintain ego boundaries and merging or being swallowed by the environment. Physical closeness or touch could precipitate panic.

Question 31

A patient diagnosed with schizophrenia and auditory hallucinations 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 behaviour?”
b. “Does what the voice tells you to do frighten you?”
c. “Do you recognize the voice speaking to you?”
d. “What is the voice telling you to do?”

Answer 31

ANS: D
Learning what a command hallucination is telling the patient to do is important because 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 answers are of lesser importance than identifying the command.

Question 32

A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 1030. By 1200, the patient has difficulty swallowing and is drooling. By 1600, vital signs are 38.6° C; pulse 110; respirations 26; and blood pressure 150/90. The patient is diaphoretic. 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, high-cholesterol diet.
d. Neuroleptic malignant syndrome; notify health care provider stat.

Answer 32

ANS: D
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), suggests neuroleptic malignant syndrome, which is a medical emergency. The symptoms given in the scenario are not consistent with the medical problems listed in the incorrect options.

Question 33

A nurse asks a patient diagnosed with schizophrenia, “What is meant by the old saying ‘You can’t judge a book by its cover’?” Which response by the patient indicates concrete thinking?

a. “The table of contents tells what a book is about.”
b. “You can’t judge a book by looking at the cover.”
c. “Things are not always as they first appear.”
d. “Why are you asking me about books?”

Answer 33

ANS: A
Concrete thinking refers to an impaired ability to think abstractly. Concreteness is often assessed through the patient’s interpretation of proverbs. Concreteness reduces one’s ability to understand and address abstract concepts such as love or the passage of time. The incorrect options illustrate echolalia, an unrelated question, and abstract thinking.

Question 34

The nurse is developing a plan for psychoeducational sessions for several adults diagnosed with schizophrenia. Which goal is best for this group?

a. Members will gain insight into unconscious factors that contribute to their illness.
b. Members will explore situations that trigger hostility and anger.
c. Members will learn to manage delusional thinking.
d. Members will demonstrate improved social skills.

Answer 34

ANS: D
Improved social skills help patients maintain relationships with others. These relationships are important to management of the disorder. Most patients with schizophrenia think concretely, so insight development is unlikely. Not all patients with schizophrenia experience delusions.

Question 35

A client says, “Facebook has a new tracking capacity. If I use the Internet, Homeland Security will detain me as a terrorist.” Select the nurse’s best initial action.

a. Tell the client, “Facebook is a safe Web site. You don’t need to worry about Homeland Security.”
b. Tell the client, “You are in a safe place where you will be helped.”
c. Administer a prn dose of an antipsychotic medication.
d. Tell the client, “You don’t need to worry about that.”

Answer 35

ANS: B
The patient is experiencing paranoia and delusional thinking, which leads to fear. Explaining that the patient is in a safe place will help relieve the fear. It is not therapeutic to disagree or give advice. Medication will not relieve the immediate concern.

Question 36

Which finding constitutes a negative symptom associated with schizophrenia?

a. Hostility
b. Bizarre behaviour
c. Poverty of thought
d. Auditory hallucinations

Answer 36

ANS: C

Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. The distracters are positive symptoms of schizophrenia. See relationship to audience response question.

Question 37

A patient insistently indicates that she cannot take her hat off because then the aliens will be able to put thoughts into her brain. Which problem is evident?

a. Visual hallucinations
b. Thought withdrawal
c. Idea of reference
d. Thought insertion

Answer 37

ANS: D
Thought insertion is believing that another person, group of people, or external force controls one`s thoughts. There is no evidence of the distracters.

Question 38

A newly hospitalized patient experiencing psychosis says, “Red chair out town board.” Which term should the nurse use to document this finding?

a. Word salad
b. Neologism
c. Anhedonia
d. Echolalia

Answer 38

ANS:	A
Word salad (schizophasia) is a jumble of words that is meaningless to the listener and perhaps to the speaker as well, because of an extreme level of disorganization.

Question 39

A nurse at the mental health clinic plans a series of psychoeducational groups for persons newly diagnosed with schizophrenia. Which two topics take priority?

a. “The importance of taking your medication correctly”
b. “How to complete an application for employment”
c. “How to dress when attending community events”
d. “How to give and receive compliments”
e. “Ways to quit smoking”

Answer 39

ANS: A, E
Stabilization is maximized by adherence to the antipsychotic medication regimen. Because so many persons with schizophrenia smoke cigarettes, this topic relates directly to the patients’ physiological well-being. The other topics are also important but are not priority topics.

Question 40

A patient diagnosed with schizophrenia was hospitalized after arguing with co-workers and threatening to harm them. The patient is aloof and suspicious and says, “Two staff members I saw talking were plotting to kill me.” Based on data gathered at this point, which nursing diagnoses relate? Select all that apply.

a. Risk for other-directed violence
b. Disturbed thought processes
c. Risk for loneliness
d. Spiritual distress
e. Social isolation

Answer 40

ANS: A, B

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 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.