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
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.

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
Ideas of reference are misinterpretations of the verbalizations or actions of others that give special personal meanings to these behaviours; 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.

Question 3

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
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.

Question 4

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
Conventional 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.

Question 5

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
The correct response indicates the patient is experiencing paranoia. Paranoia often leads to fearfulness, and the patient may attempt to strike out at others to protect self. The distracters are comforting hallucinations or do not indicate paranoia.

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
Clues to hallucinations include eyes looking around the room as though to find the speaker, tilting the head to one side as though listening intently, and grimacing, mumbling, or talking aloud as though responding conversationally to someone.

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
Aripiprazole is a third-generation atypical antipsychotic 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, 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.

Question 8

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

ANS: 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

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 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 12

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 13

Which finding constitutes a negative symptom associated with schizophrenia?
a.Hostility
b.Bizarre behaviour
c.Poverty of thought
d.Auditory hallucinations

Answer 13

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 14

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 14

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 15

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 15

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 16

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 16

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

Question 17

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 17

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 18

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 18

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 19

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 19

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 20

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 20

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 21

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 21

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 22

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 22

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 23

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 23

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 24

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 24

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 25

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 25

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.