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20 Cards in this Set
- Front
- Back
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Mark, a 32-year-old patient with schizophrenia, is found in a closet with an empty 2-liter bottle of cola taken from the staff refrigerator. The bottle had been full. The patient has also been drinking more from the hallway water cooler and taking drinks from his peers’ dinner trays. Recently, staff has noticed an increase in auditory hallucinations and the onset of confusion. Which response is most appropriate? a.Place Mark on every-15-minute checks to identify any further deterioration. b.Restrict his access to fluids, and evaluate for water intoxication via daily weights. c.Attempt to distract the patient from excess fluid intake and other bizarre behavior. d.Request an increase in anti-psychotic medication, owing to the worsening of his psychosis. |
b.Restrict his access to fluids, and evaluate for water intoxication via daily weights. Rationale: Conventional anti-psychotics have adverse effect of urinary hesitancy/retention. Varcarolis |
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Jordan is a 21-year-old who was recently diagnosed with schizophrenia. He has had to drop out of college as the positive symptoms of his disease have made it impossible for him to pursue his dream of being an architect. He presents to the emergency department with flat affect, depressed mood, and having auditory hallucinations telling him he is “no good to anyone anymore.” Which of the following statement is true regarding depression and schizophrenia? a. Anxiety and substance abuse are comorbid with schizophrenia, but not depression or dysphoria. b. It is important to assess for depression in patients with schizophrenia, but suicide rarely occurs in this population of clients. c. Assessing for depression and suicidal ideation in patients with schizophrenia is important since almost half of people with schizophrenia will attempt suicide. d. The medications that will be given to control the positive symptoms of schizophrenia, such as auditory hallucinations, will alleviate any depressive symptoms a patient may have. |
c. Assessing for depression and suicidal ideation in patients with schizophrenia is important since almost half of people with schizophrenia will attempt suicide. Rationale: Jordan has positive of auditory hallucinations) but is experiencing affective symptoms of flat affect and hopelessness which risks becoming a command hallucination to do self-harm. Suicide rates are high amongst those diagnosed with schizophrenia. Varcarolis |
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Tony, a 45-year-old patient with schizophrenia, sometimes moves his lips silently or murmurs to himself when he does not realize others are watching. Sometimes when talking to others, he suddenly stops, appears distracted for a moment, and then resumes. Based on these observations, Tony most likely is experiencing: a. Illusions b. Delusional thinking c. Auditory hallucinations d. Impaired reality testing |
c. Auditory hallucinations Rationale: Since Tony pauses and is distracted during during a conversation that is not a natural conversation pause, it is likely that his attention is elsewhere, as if listening to another party, eluding to his having an auditory hallucination. Varcarolis |
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Julia, a 28-year-old diagnosed with schizophrenia, is encouraged to attend groups but stays in her room instead. Staff and peers encourage her participation, but without success. Her hygiene is poor despite encouragement to shower and brush her teeth. She does not seem concerned that others wish she would behave differently. Which is the most likely explanation for Julia’s failure to respond to others’ efforts to help her behave in a more adaptive fashion? Select all that apply. a. She is displaying avolition. b. She is displaying anergia. c. She is displaying negativism. d. She is exhibiting paranoid delusions. e. She is being resistant or oppositional. f. She is apathetic due to her schizophrenia. |
a. She is displaying avolition. b. She is displaying anergia. Avolition is the decrease in motiviation to initiate or participate in purposeful activities. Anergia is the lack of energy. Negativisim is passively not doing what is asked, or actively doing the opposite of what is being asked. Paranoid delusions is being excessively concerned that someone/thing is out to get them, when there isn't. Resistant/oppositional is refusing and being defiant. Apathetic is not caring about something. Varcarolis |
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Kyle, a 23-year-old patient with schizophrenia, has been admitted to the psychiatric unit for one week. He has begun to take the first- generation antipsychotic haloperidol (Haldol). One day you find him sitting very stiffly and not moving. He is diaphoretic, and when you ask if he is okay he seems unable to turn towards you or to respond verbally. You obtain vital signs, which are as follows: BP 170/100, P 110, T 103. What are the priority nursing interventions? Select all that apply. a. Begin to wipe him with a washcloth wet with cold water or alcohol. b. Hold his medication, and contact his provider stat. c. Administer a medication such as benztropine IM to correct his dystonic reaction. d. Reassure him that although there is no treatment for his tardive dyskinesia, it will pass. e. Explain that he has anticholinergic toxicity, hold his meds, and give IM physostigmine. f. Hold his medication tonight, and consult his provider after completing medication rounds. |
a. Begin to wipe him with a washcloth wet with cold water or alcohol. b. Hold his medication, and contact his provider stat. This patient has developed NEUROLEPTIC MALIGNANT SYNDROME due to the conventional anti-psychotic displaying with: sudden high fever, blood pressure fluctuations, dysrhythmmias, muscle rigidity, change in level of consciousness, or even coma. Interventions: Hold medications and notify provider.Monitor vitals, apply cooling blankets, increase fluid intake, administer antipyretics,, administer dantriolene (Dantrium) and bromocriptine (Parlodel) for muscle relaxation. Varcarolis |
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A nurse is caring for a client who has substance-induces psychotic disorder and is experiencing auditory hallucinations. The client states, "The voices won't leave me alone!" Which of the following statements by the nurse are appropriate? (Select all that apply.) a. "When did you start hearing the voices?" b. "The voices are not real, or else we would both hear them." c. "It must be scary to hear voices." d. "Are the voices telling you to hurt yourself?" e. "Why are the voices talking only to you?" |
a. "When did you start hearing the voices?" c. "It must be scary to hear voices." d. "Are the voices telling you to hurt yourself?" Always try to see through the patient's eyes. Convey empathy of the patient's fears and avoid questioning the content of the hallucination of itself, such as in a doubtful manner (answer b and e). ATI RN Mental Health Chapter 14 |
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A nurse is completing an admission for a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms? (Select all that apply.) a. auditory hallucinations b. lack of motivation c. use of clang associations d. delusion of persecution e. constantly waving arms f. flat affect |
a. auditory hallucinations c. use of clang associations d. delusion of persecution e. constantly waving arms lack of motivation and flat affect are negative symptoms. ATI RN Mental Health Chapter 14 |
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A nurse is caring for a client who has schizophrenia disorder. Which of the following statements indicates the client is experiencing depersonalization? a. "I am a superhero and am immortal." b. "I am no one, and everyone is me." c. "I feel monsters pinching me all over." d. "I know that you are stealing my thoughts." |
b. "I am no one, and everyone is me." This displays a loss of identity. Superhero/immortal is a delusion of grandeur, monsters pinching is a tactile hallucination, and thoughts being stolen is thought withdrawal. ATI RN Mental Health Chapter 14 |
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A nurse is speaking with a client who has schizophrenia when he suddenly seems to stop focusing on the nurse's questions and begins looking at the ceiling and talking to himself. Which of the following actions should the nurse take? a. Stop the interview at this point, and resume later when the client is better able to concentrate. b. Ask the client. "Are you seeing something on the ceiling?" c. Tell the client, "You seem to be looking at something on the ceiling. I see something there, too." d. Continue the interview without comment on the client's behavior. |
b. Ask the client. "Are you seeing something on the ceiling?" Again, asking the patient to establish that they're having a hallucination is acceptable. However, doubting or disregarding it is unacceptable practice (a,d). Do not play into the hallucination (c). ATI RN Mental Health Chapter 14 |
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A nurse us caring for a client on an acute mental health unit. The client reports hearing voices that are telling her to "kill your doctor." Which of the following is the priority action for the nurse to take? a. Use therapeutic communication to discuss the hallucination with the client. b. Initiate one-to-one observation of the client. c. Focus the client on reality. d. Notify the provider of the client's statement. |
b. Initiate one-to-one observation of the client. You always initiate one-to-one observation of a client that has command hallucinations that are posing harm. If the harm is aimed at another client, then remove the other client from the area also. ATI RN Mental Health Chapter 14 |
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A nurse us caring for a client who has schizophrenia and exhibits a lack of gropming and a flat affect. The nurse should anticipate a prescription of which of the following medications? a. chlorpromazine (Thorazine) b. thiothixene (Navene) c. risperidone (Risperdal) d. haloperidol (Haldol) |
c. risperidone (Risperdal) Risperidone (Risperdal) is an unconventional or atypical (2nd gen) anti-psychotic. This generation medication is effective for treating negative symptoms of schizophrenia. chlorpromazine (Thorazine), thiothixene (Navene), and haloperidol (Haldol)are all conventional (1st gen) anti-psychotics and are most effective on positive symptoms of schizophrenia ATI RN Mental Health Chapter 22 |
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A nurse is caring for a client who takes ziprasidone (Geodon). The client reports difficulty swallowing the oral medication and becomes extremely agitated with injectable administration. The nurse should contact the provider to discuss a change to which of the following medications? (select all that apply.) a. olanzapine (Zyprexa) b. quetiapine (Seroquel) c. aripiprazole (Abilify) d. clozapine (Clozaril) e. paliperidone (Invega) |
c. aripiprazole (Abilify) d. clozapine (Clozaril) Aripiprazole (Abilify) and clozapine (Clozaril)are both available in oral disintegrating tablets. ATI RN Mental Health Chapter 22 |
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A charge nurse is discussing manifestations of schizophrenia with a newly licensed nurse. Which of the following should the charge nurse identify as being effectively treated by conventional anti-psychotics? (select all that apply.) a. auditory hallucinations b. withdrawal from social situations c. delusions of grandeur d. severe agitation e. anhedonia |
a. auditory hallucinations c. delusions of grandeur d. sever agitation These are all POSITIVE symptoms. Withdrawal from social situations and anhedonia are both negative symptoms, and would likely be treated with an unconventional/atypical 2nd gen anti-psychotic. ATI RN Mental Health Chapter 22 |
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A nurse is assessing a client who is currently taking perphenazine. Which of the following findings should the nurse identify as an extrapyramidal symptom (EPS)? (Select all that apply.) a. decreased level of consciousness b. drooling c. involuntary arm movements d. urinary retention e. continual pacing |
b. drooling c. involuntary arm movements e. continual pacing EPS includes: -acute dystonia (spasm of tongue, neck, face and back), -parkisonism (bradykinesia, rigidity, shuffling gait, drooling, tremors) -akathisia (inability to sit/stand still, continual pacing) -tardive dyskinesia or TD (involuntary movements of tongue and face--> lip smacking; involuntary movements or arms, legs and trunk) ATI RN Mental Health Chapter 22 |
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A nurse is providing discharge teaching for a client who has schizophrenia and a new presription for iloperidone (Fanapt). Which of the following client statements indicates understanding of the teaching? a. "I will be able to stop taking this medication as soon as I feel better." b. "If I feel frowsy during the day, I will stop taking this medication and call my provider." c. "I will be careful not to gain too much weight while taking this medication." d. "This medication is highly addictive and must be withdrawn slowly." |
c. "I will be careful not to gain too much weight while taking this medication." A side effect for Unconventional/atypical 2nd gen anti-psychotics is weight gain, as well as risk of DM. Once on meds for this disorder, never off-->only med switches. While a majority of neurological disorder medications must be titrated on or off, these drugs are not addictive. ATI RN Mental Health Chapter 22 |
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A 25-year-old man is admitted to the psychiatric unit after being found by the police walking naked down the middle of the street at 3:00 AM. In conducting the health history, the nurse identifies some of the following social risk factors as possible predictors of a diagnosis of schizophrenia. (Select all that apply): A. Urban residence. B. Recent immigration. C. Impaired physical or mental health. D. Older paternal age. E. First-degree relative diagnosed with schizophrenia. F. Ethnic and racial discrimination. |
A. Urban residence. B. Recent immigration. F. Ethnic and racial discrimination. SOCIAL risk factors. Giddens Chapter 32 |
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A 25-year-old man is admitted to the psychiatric unit after being found by the police walking naked down the middle of the street at 3:00 AM. While watching television, he appears to be hallucinating. He is swearing loudly at the television and is becoming increasingly agitated. Which of the following nursing interventions would be appropriate in dealing with this patient? (Select all that apply): A. In a firm voice, tell the patient to stop this behavior. B. Acknowledge the presence of the hallucinations. C. Instruct other team members to ignore the patient's behavior. D. Reassure the patient that he is not in any danger. E. Give simple commands in a calm voice. |
B. Acknowledge the presence of the hallucinations. D. Reassure the patient that he is not in any danger. E. Give simple commands in a calm voice. It's never appropriate to tell the patient to stop behaving as such, or to ignore the behavior. Giddens Chapter 32 |
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A 25-year-old man is admitted to the psychiatric unit after being found by the police walking naked down the middle of the street at 3:00 AM. He insists that he is the real Santa Claus. Which of the following nursing interventions should the nurse implement when working with this patient? A. Consistently use the patient's name. B. Point out to the patient why he cannot be Santa Claus. C. Agree that he is Santa Claus so as not to upset him further. D. Provide medication as needed (PRN). |
A. Consistently use the patient's name. Use reality orientation. Don't reinforce hallucination or argue with patient about it. Meds that are PRN are not sufficient for this disorder. Giddens Chapter 32 |
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A 20-year old male patient diagnosed with chronic schizophrenia is placed on fluphenazine (Prolixin), a typical antipsychotic, 20 mg. twice a day. At the evening medication time, he expresses that he is not feeling well. The nurse assesses the patient and finds the following symptoms: oral temperature 103 °F (39.4 °C), pulse 110 beats/min, and respirations 24 breaths/min. The patient is diaphoretic and appears rigid. This patient is most likely suffering from which of the following? A. Tardive dyskinesia B. Pneumonia C. Neuroleptic malignant syndrome D. Pseudoparkinsonism |
C. Neuroleptic malignant syndrome This patient is displaying the indicators of neuroleptic malignant syndrome due to a conventional (1st) gen medication. Giddens Chapter 32 |
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A 50-yeard-old female patient is admitted to the psychiatric unit for an acute exacerbation of paranoid schizophrenia after she stopped taking her medications for several months. She tells the nurse that she believes her food is being poisoned, and she refuses to eat. The most appropriate intervention by the nurse is to A. provide canned food while expressing reasonable doubt. B. agree with the patient's decision. C. challenge the patient's delusion. D. dismiss her fears and insecurities. |
A. provide canned food while expressing reasonable doubt. Canned food can offset the patient's paranoid suspicions in order to get the patient to eat. Giddens Chapter 32 |
