Chapter 17: Schizophrenia Spectrum Disorders Flashcards
- A person diagnosed with schizophrenia has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today the person shouts, Theyre all plotting to destroy me. Select the nurses 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.
ANS: B
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 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 behavior as:
a. echolalia.
b. an idea of reference.
c. a delusion of infidelity.
d. an auditory hallucination.
ANS: B
Ideas of reference are misinterpretations of the verbalizations or actions of others that give special personal meanings to these behaviors; for example, when seeing two people talking, the individual assumes they are talking about him or her. The other terms do not correspond with the scenario.
- A patient diagnosed with schizophrenia says, My co-workers are out to get me. I also saw two doctors plotting to overdose me. How does this patient perceive the environment?
a. Disorganized
b. Unpredictable
c. Dangerous
d. Bizarre
ANS: C
The patient sees the world as hostile and dangerous. This assessment is important because the nurse can be more effective by using empathy to respond to the patient. Data are not present to support any of the other options.
- 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 common side effects should the nurse 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
ANS: A
Typical antipsychotic drugs often produce sedation and extrapyramidal side effects such as stiffness and gait disturbance, effects the patient might describe as making him or her feel like a robot. The side effects mentioned in the other options are usually not associated with typical antipsychotic therapy or would not have the effect described by the patient.
- A nurse works with a patient diagnosed with schizophrenia regarding the importance of medication management. The patient repeatedly says, I dont like taking pills. Which treatment strategy should the nurse discuss with the health care provider?
a. Use of a long-acting antipsychotic injections
b. Addition of a benzodiazepine, such as lorazepam (Ativan)
c. Adjunctive use of an antidepressant, such as amitriptyline (Elavil)
d. Inpatient hospitalization because of the high risk for exacerbation of symptoms
ANS: A
Medications such as 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 patients dislike of taking pills.
- A patients care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating?
a. Aloofness, haughtiness, suspicion
b. Darting eyes, tilted head, mumbling to self
c. Elevated mood, hyperactivity, distractibility
d. Performing rituals, avoiding open places
ANS: B
Clues to hallucinations include looking around the room as though to find the speaker; tilting the head to one side as though intently listening; and grimacing, mumbling, or talking aloud as though responding conversationally to someone.
- A health care provider considers which antipsychotic medication to prescribe for a patient diagnosed with schizophrenia who has auditory hallucinations and poor social functioning. The patient is also overweight and has hypertension. Which drug should the nurse advocate?
a. clozapine (Clozaril)
b. ziprasidone (Geodon)
c. olanzapine (Zyprexa)
d. aripiprazole (Abilify)
ANS: D
Aripiprazole is an atypical antipsychotic medication that is effective against both positive and negative symptoms of schizophrenia. It causes little or no weight gain and no increase in glucose, high- or low-density lipoprotein cholesterol levels, or triglycerides, making it a reasonable choice for a patient with obesity or heart disease. Clozapine may produce agranulocytosis, making it a poor choice as a first-line agent. Ziprasidone may prolong the QT interval, making it a poor choice for a patient with cardiac disease. Olanzapine fosters weight gain.
- A patient diagnosed with schizophrenia tells the nurse, I eat skiller. Tend to end. Easter. It blows away. Get it? Select the nurses 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.
ANS: D
When a patients 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. 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.
- A patient diagnosed with schizophrenia has catatonia. The patient has little spontaneous movement and waxy flexibility. Which patient needs are of priority importance?
a. Psychosocial
b. Physiologic
c. Self-actualization
d. Safety and security
ANS: B
Physiologic 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 physiologic integrity. The assessment findings do not suggest safety concerns. Higher level needs (psychosocial and self-actualization) are of lesser concern.
- A patient diagnosed with schizophrenia has catatonia. The patient is stuporous, demonstrates little spontaneous movement, and has waxy flexibility. The patients activities of daily living are severely compromised. An appropriate outcome is that the patient will:
a. demonstrate increased interest in the environment by the end of week 1.
b. perform self-care activities with coaching by the end of day 3.
c. gradually take the initiative for self-care by the end of week 2.
d. voluntarily accept tube feeding by day 2.
ANS: B
Outcomes related to self-care deficit nursing diagnoses should deal with increasing the patients ability to perform self-care tasks independently, such as feeding, bathing, dressing, and toileting. Performing the tasks with coaching by the nursing staff denotes improvement over the complete inability to perform the tasks. The incorrect options are not directly related to self-care activities; they are difficult to measure and are unrelated to maintaining nutrition.
- A nurse observes a patient who is diagnosed with schizophrenia. The patient is 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
ANS: B
Waxy flexibility is the ability to hold distorted postures for extended periods, 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.
- Which patient diagnosed with schizophrenia would be expected to have the lowest level of overall functioning?
a. 39 years old; paranoid ideation since age 35 years
b. 32 years old; isolated episodes of catatonia since age 24 years; stable for 3 years
c. 19 years old; diagnosed with schizophreniform disorder 6 months ago
d. 40 years old; frequent relapses since age 18; often does not take medication as prescribed
ANS: D
The 40-year-old patient who has been diagnosed with schizophrenia since 18 years of age could logically be expected to have the lowest overall level of functioning secondary to deterioration associated with frequent relapses. The 39-year-old patient who has had paranoid ideation since 35 years of age could be expected to have a higher level because schizophrenia of short duration may be less impairing than other types. The patient who has had episodes of catatonia since the age of 24 years has been stable for more than 3 years, suggesting a higher functional ability. The 19-year-old patient diagnosed with schizophreniform disorder has been ill for only 6 months, and disability is likely to be minimal.
- A patient with delusions of persecution about being poisoned has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the patient?
a. Allow the patient to have supervised access to food vending machines
b. Allow the patient to telephone a local restaurant to deliver meals
c. Offer to taste each portion on the tray for the patient
d. Begin tube feedings or total parenteral nutrition
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 considered aggressive and usually promote violence. Patients often perceive foods in sealed containers, packages, or natural shells as being safe.
- 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 nurses best plan.
a. Visit daily for 4 days, then visit every other day for 1 week; stay with the 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 patients arm; leave if the patient does not respond within 10 minutes.
d. Visit every other day; remind the patient of the nurses identity; encourage the patient to talk while the nurse works on reports.
ANS: A
Severe constraints on the community mental health nurses 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 patients own level, with silence accepted. Short periods of contact are helpful to minimize both the patients and the nurses 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 leveling 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.
- Patients diagnosed with schizophrenia who are suspicious and withdrawn:
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.
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 defense against uncomfortable levels of anxiety. When someone attempts to establish a relationship with such a patient, the patients 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 newly admitted patient diagnosed with schizophrenia says, The voices are bothering me. They yell and tell me Im bad. I have got to get away from them. Select the nurses 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 the voices. Ask some other patients to sit and talk with you.
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 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 taken fluphenazine (Prolixin) 5 mg orally twice daily for 3 weeks. The nurse now assesses 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
ANS: C
Pseudoparkinsonism induced by antipsychotic medication mimics the symptoms of Parkinson disease. It frequently appears within the first month of treatment. Hepatocellular effects would produce abnormal liver test results. Neuroleptic malignant syndrome is characterized by autonomic instability. Akathisia produces motor restlessness.
- A patient diagnosed with schizophrenia is acutely disturbed and violent. After several doses of haloperidol (Haldol), the patient is calm. Two hours later the nurse sees the patients head rotated to one side in a stiff position; the lower jaw is thrust forward, and the patient is drooling. Which problem is most likely?
a. Acute dystonic reaction
b. Tardive dyskinesia
c. Waxy flexibility
d. Akathisia
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 that require 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 observed in catatonic schizophrenia. Akathisia is evidenced by internal and external restlessness, pacing, and fidgeting.
- An acutely violent patient diagnosed with schizophrenia receives several doses of haloperidol (Haldol). Two hours later the nurse notices the patients 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 (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 subcutaneously from the PRN medication administration record.
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; therefore, the intramuscular route is best. In this case, the best option given is diphenhydramine.
- A patient has taken trifluoperazine (Stelazine) 30 mg/day orally for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patients neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect?
a. Agranulocytosis
b. Tardive dyskinesia
c. Tourette syndrome
d. Anticholinergic effects
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 observed. 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 syndrome is a condition in which tics are present. Anticholinergic effects include dry mouth, blurred vision, flushing, constipation, and dry eyes.
- 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 nurses best response.
a. Why are you laughing?
b. Please share the joke with me.
c. I dont think I said anything funny.
d. You are laughing. Tell me whats happening.
ANS: D
The patient is likely laughing in response to inner stimuli such as hallucinations or fantasy. Focusing on the hallucinatory clue (i.e., the patients laughter) and then eliciting the patients 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.
- Which symptoms are expected for a patient diagnosed with schizophrenia who has disorganization?
a. Extremes of motor activity, from excitement to stupor
b. Social withdrawal and ineffective communication
c. Severe anxiety with ritualistic behavior
d. Highly suspicious, delusional behavior
ANS: B
Patients with disorganization demonstrate the most regressed and socially impaired behaviors. Communication is often incoherent, with silly giggling and loose associations predominating. Highly suspicious, delusional behavior relates more to paranoia. Extremes of motor activity, from excitement to stupor, relate to catatonia. Severe anxiety and ritualistic behaviors relate to obsessive-compulsive disorder.
- 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 behavior, echopraxia, echolalia, and waxy flexibility
d. Loose associations, concrete thinking, and echolalia neologisms
ANS: A
Withdrawal, misinterpreting, poor concentration, and preoccupation with religion are prodromal symptoms, which are the symptoms present before the development of florid symptoms. The incorrect options each list the positive symptoms of schizophrenia that are more likely to be apparent during the acute stage of the illness.
- A patient diagnosed with schizophrenia says, Everyone has skin lice that jump on you and contaminate your blood. Which problem is evident?
a. Poverty of content
b. Concrete thinking
c. Neologisms
d. Paranoia
ANS: D
The patients unrealistic fear of contamination indicates paranoia. Neologisms are invented words. Concrete thinking involves literal interpretation. Poverty of content refers to an inadequate fund of information.
- A patient diagnosed with schizophrenia has paranoid thinking. The patient angrily tells a nurse, You are mean and nasty. No one trusts you or wants to be around you. Select the most likely analysis. The patient:
a. is trying to manipulate the nurse by using negative comments.
b. is likely to experience disorganization and catatonia in the near future.
c. is jealous of the nurses position of power in the relationship.
d. may be identifying another persons shortcomings in order to preserve his or her own self-esteem.
ANS: D
Patients with paranoid ideation often use disparaging comments to preserve ones own self-esteem. There is no evidence the patient is trying to manipulate the nurse or is jealous. This behavior is not predictive of catatonia or disorganization.
- 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
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 ones thoughts.
- 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 expects a change to which medication?
a. haloperidol (Haldol)
b. olanzapine (Zyprexa)
c. chlorpromazine (Thorazine)
d. diphenhydramine (Benadryl)
ANS: B
Olanzapine is an atypical antipsychotic medication that targets both positive and negative symptoms of schizophrenia. Haloperidol and chlorpromazine are conventional antipsychotic agents that target only positive symptoms. Diphenhydramine is an antihistamine.
- The family of a patient diagnosed with schizophrenia is unfamiliar with the illness and the familys role in recovery. Which type of therapy should the nurse recommend?
a. Psychoeducational
b. Psychoanalytic
c. Transactional
d. Family
ANS: A
A psychoeducational group explores the causes of schizophrenia, the role of medications, the significance of medication compliance, and the importance of support for the ill member of the family, and also provides recommendations for living with a person with schizophrenia. Such a group can be of practical assistance to the family members. The other types of therapy do not focus on psychoeducation.
- 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, Demons are in the basement and they can come through the floor. The nurse can correctly assess this information as an indication of:
a. need for psychoeducation
b. medication noncompliance
c. chronic deterioration
d. relapse
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 regularly taking his or her medication. Psychoeducation is more effective when the patients symptoms are stable. Chronic deterioration is not the best explanation.
- A patient diagnosed with schizophrenia begins to talks about cracklomers in the local shopping mall. The term cracklomers should be documented as:
a. neologism.
b. concrete thinking.
c. thought insertion.
d. an idea of reference.
ANS: A
A neologism is a newly coined word having special meaning to the patient. Cracklomers is not a known word. Concrete thinking refers to the inability to think abstractly. Thought insertion refers to thoughts of others that are implanted in ones mind. An idea of reference is a type of delusion in which trivial events are given personal significance.
- 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:
a. sit close to the patient.
b. place an arm protectively around the patients shoulders.
c. place a hand on the patients arm and exert light pressure.
d. maintain a normal social interaction distance from the patient.
ANS: D
The patient is describing phenomena that indicate personal boundary difficulties. The nurse should maintain an appropriate social distance and not touch the patient, because the patient is anxious about the inability to maintain ego boundaries and merging with or being swallowed by the environment. Physical closeness or touch could precipitate panic.
- A patient diagnosed with schizophrenia has auditory hallucinations. The patient anxiously tells the nurse, The voice is telling me to do things. Select the nurses 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?
ANS: D
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.
- A patient receiving risperidone (Risperdal) 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 per minute; respirations, 26 breaths per minute; and blood pressure, 150/90 mm Hg. Select the nurses 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.
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), 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 begins a new prescription for lurasidone HCl (Latuda). The patient is 5?26?3? tall and currently weighs 204 pounds. 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
ANS: B Lurasidone HCl (Latuda) is an atypical antipsychotic medication. The incidence of weight gain, diabetes, and high cholesterol is high with this medication. The patient is overweight now, so weight management is especially important. The incidence of tardive dyskinesia is low with atypical antipsychotic medications. Constipation may occur, but it is less important than weight management. This drug usually produces drowsiness.
- A patient diagnosed with schizophrenia has auditory hallucinations, delusions of grandeur, poor personal hygiene, and motor agitation. 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. Motor agitation
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 distractors are positive symptoms of schizophrenia.
- The family members of a patient newly diagnosed with schizophrenia state that they do not understand what has caused the illness. The nurses response should be based on which models? Select all that apply.
a. Neurobiological
b. Environmental
c. Family theory
d. Genetic
e. Stress
ANS: A, D
Compelling evidence exists that schizophrenia is a neurologic disorder probably related to neurochemical abnormalities, neuroanatomical disruption of brain circuits, and genetic vulnerability. Stress and family disruption may contribute but are not considered etiologic factors. Environmental factors are not recognized as causative variables in schizophrenia.
- A nurse at the mental health clinic plans a series of psychoeducational groups for persons diagnosed with schizophrenia. Which two topics would take priority?
a. How to complete an application for employment
b. The importance of correctly taking your medication
c. How to dress when attending community events
d. How to give and receive compliments
e. Ways to quit smoking
ANS: B, E
Stabilization is maximized by the adherence to the antipsychotic medication regimen. Because so many patients with schizophrenia smoke cigarettes, this topic relates directly to the patients physiologic well-being. The other topics are also important but are not priority topics.
- A patient diagnosed with schizophrenia is 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 assault 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
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 patients 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.
