Chapter 4 Flashcards
A newly admitted patient has the diagnosis of catatonic schizophrenia. Which behavior observed in the patient supports that diagnosis?
Maintains an immobilized state for hours
What would be an appropriate short-term outcome for a patient diagnosed with residual schizophrenia who exhibits ambivalence?
Choose between two outfits to wear each morning.
What is the priority nursing diagnosis for a catatonic patient?
Risk for deficient fluid volume
Which nursing diagnosis is appropriate for a patient who insists being called Your Highness and demonstrates loosely associated thoughts?
Disturbed thought processes
Which initial short-term outcome would be appropriate for a patient who was admitted expressing delusional thoughts?
Engage in reality-oriented conversation.
Which assessment observation supports a patients diagnosis of disorganized schizophrenia?
Consistent inappropriate laughing
Which of the following interventions should the nurse plan to use to reduce patient focus on delusional thinking?
Focusing on feelings suggested by the delusion
A patient tried to gouge out his eye in response to auditory hallucinations commanding, If thine eye offends thee, pluck it out. The nurse would analyze this behavior as indicating:
Impaired impulse control
An appropriate intervention for a patient with an identified nursing diagnosis of situational low self-esteem would be:
Engaging patient in activities designed to permit success
A 19-year-old patient is admitted for the second time in 9 months and is acutely psychotic with a diagnosis of undifferentiated schizophrenia. The patient sits alone rubbing her arms and smiling. She tells the nurse her thoughts cause earthquakes and that the world is burning. The nurse assesses the primary deficit associated with the patients condition as:
Disturbed thinking
A patient has been admitted with disorganized type schizophrenia. The nurse observes blunted affect and social isolation. He occasionally curses or calls another patient a jerk without provocation. The nurse asks the patient how he is feeling, and he responds, Everybody picks on me. They frobitz me. The patients communication exhibits:
A neologism
A patient has been admitted with disorganized type schizophrenia. The nurse asks the patient how he is feeling, and he responds, Everybody picks on me. They frobitz me. The best response for the nurse to make would be:
Who do you mean when you say everybody?
Which patient behavior would support the diagnosis of residual schizophrenia with negative symptoms?
Shows no emotion when telling the story of a sisters recent death
By discharge, which outcome is appropriate for a patient who hears voices telling him he is evil?
Identify events that increase anxiety and promote hallucinations.
Which response by the nurse would best assist a patient in de-escalating aggressive behavior?
Tell me whats going on
A 34-year-old male admitted with catatonic schizophrenia has been mute and motionless for several days while at home prior to admission. He still appears stuporous in the hospital. Which nursing intervention would be an initial priority?
Assessing the patient for physical problems
Which response is appropriate when a patients mother expresses guilt over causing my child to be schizophrenic?
New findings suggest this disorder is biological in nature.
Which response demonstrates both empathy and understanding of the relationship genetics has to the development of schizophrenia in twins?
In fraternal twins, the chance of the other twin developing the disorder is quite small.
The wife of a patient diagnosed with paranoid schizophrenia asks, Ive been told that my husbands illness is probably related to imbalanced brain chemicals. Can you be more specific? The response based on the dopamine hypothesis is:
An increase in the brain chemical dopamine explains the presence of delusions and hallucinations
What is the basis for the reduction in disturbed thought processes when a patient is administered haloperidol (Haldol)?
Dopamine receptors are blocked, making dopamine less available
During a treatment team meeting, the point is made that a patient with schizophrenia has recovered from the acute psychosis but continues to demonstrate apathy, avolition, and blunted affect. The nurse who relates these symptoms to serotonin (5HT2) excess will suggest that the patient receive:
Olanzapine (Zyprexa)
What response would be anticipated when a patient who received chlorpromazine (Thorazine) for 15 years to treat schizophrenia is switched to Seroquel (quetiapine)?
Improvement in tardive dyskinesia
A patient admitted with the diagnosis of schizophreniform disorder R/O organic pathology. Based on this information, the nurse can expect that the patient will:
Be scheduled for a magnetic resonance imaging (MRI) test
In planning aftercare for a patient with schizophrenia and whose insurance benefits have been exhausted, the nurse who is concerned about overcoming negative symptoms will make provisions for the patient to have stimulation, structure, socialization, and support. Which option would best incorporate these factors?
Attending a psychosocial club
A patient with catatonic schizophrenia has been standing with his left arm upraised and his right foot off the floor for the majority of the last 20 hours, eating only when allowed to eat standing up. Which nursing intervention has priority for this patient?
Assessing for lower extremity edema bid
Which nursing action best addresses the needs of a paranoid patient who believes the food is poisoned?
Allowing the patient to select food from vending machines
Prior to discharge, the nurse plans to teach the patient and family about relapse. Which items will the nurse include in the teaching?
Recognizing warning signs of relapse
Because of the cognitive disturbances associated with schizophrenia, which technique will be useful as the nurse teaches a patient about self-management?
Teach material in small segments
The wife of a patient newly diagnosed with paranoid schizophrenia is concerned that her husband will be this sick for the rest of his life. What information can the nurse provide to the wife?
This disorder generally responds well with treatment and follow-up.
A patient is exhibiting auditory hallucinations in addition to being forgetful and easily confused. Which diagnosis does the nurse base this patients interventions on?
Impaired cognitive functioning
A patient experiences intrusive, insulting auditory hallucinations. Which independent behavioral technique can the nurse teach the patient to employ when the voices are troublesome?
Sing or whistle to compete with the voices.
A patient with schizophrenia tells the nurse as they sit in the day room, I hear voices telling me bad things. The most therapeutic response the nurse can make is:
I believe you hear voices, but I dont hear them myself.
A patient tells the nurse, When Im in the day room, I hear people whispering about me, and that makes me want to punch them. What direction will the nurse provide the staff regarding interacting with this patient?
Treat this patient matter-of-factly. Be direct; don’t talk about him or others in his presence.
A patient with schizophrenia is medication compliant and has well-controlled symptoms. He has, however, never been successful in holding a job because of poor social skills and lack of understanding of basic job skills. The nurse case manager should consider referring the patient:
For psychosocial rehabilitation
A patient prescribed an antipsychotic medication develops a high fever, unstable blood pressure, and muscle rigidity. Her next dose of medication is due. The nurse should:
Hold the medication and immediately describe the patients symptoms to the doctor.
Which interventions will the nurse implement to preserve milieu safety when a patient becomes agitated? Select all that apply.
a. Project confidence and control.
b. Provide a show of force when appropriate.
c. Ask the agitated patient why they are feeling so aggressive.
d. Move to within 5 feet of the patient to help contain their movement.
A, B, E
Which interventions will the nurse implement to assure effective staff crises management skills? Select all that apply.
a. Schedule regular staff crises simulations.
b. Encourage the staff to discuss the details of unit crises.
c. Attempt to identify staff who are ineffective during crises.
d. Review documentation that describe the details of unit crises.
e. Review unit crises management policies for needed updates.
A, B, D, E
