The nurse asks Mr. Tyler what he would like to be called. He replies, “You’ve seen me on TV. My name is Bob!” The nurse assesses that Bob’s behavior is guarded and suspicious. Based on this, what is the most important nursing intervention?
Establish rapport and trust ~ sometimes more readily established through nonverbal communication
What is the most accurate assessment if the client believes that the healthcare providers are FBI agents and that there are cameras in his apartment to monitor his moves?
The nurse understands that Bob has a thought disorder rather than a mood disorder. Thought disorders include psychosis and schizophrenia. Which behavior is characteristic of a thought disorder?
The nurse completes the mental status exam and records that Bob’s grooming and hygiene are fair. Bob continually paces the hall and is unable to sit still for longer than 1 or 2 minutes. His speech is rapid and difficult to follow. He describes his mood as “blase”. His affect is anxious, and his facial expression is flat with a blank smile. He is inattention and appears distracted. The nurse understands that schizophrenia can be differentiated from psychosis by which assessment?
Negative symptoms ~ characteristic of schizophrenia and include behaviors such as minimal eye contact, poor grooming and hygiene and apathy
Which findings depicts negative symptoms of schizophrenia?
Flat affect and social inattentiveness ~ ‘spaciness” are examples of negative symptoms characteristics of schizophrenia
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Which nursing problem has priority?
Disturbed thought processes
Bob is unable to report his current med regimen, so the nurse contacts his case worker. Additional info from the case worker indicates that Bob has been sleeping only 3-4hrs each night for the past few nights. Bob has demonstrated less energy and states that he feels “really bad and pretty down”. The case worker reports that Bob was taking Prolixin 5mg in the morning and 10mg at bedtime, along with Cogentin 2mg BID because he cannot afford the newer antipsychotics. Why is Prolixin prescribed?
Disorganized thoughts ~ antipsychotic meds are useful to manage symptoms related to cognitive impairment (delusions, hallucinations) as well as behaviors related to agitation and aggression
A patient with schizophrenia will experience which benefit from Prolixin if administered intramuscularly?
Maintain long-term med compliance
Bob refuses treatment and wants to leave the ED. He is admitted involuntarily for 96 hours. What behavior validates the need for involuntary hospitalization?
Violence towards father ~ risk of violence is a criterion for involuntary hospitalization
If someone who has voluntarily chosen to be hospitalized should want to leave the hospital, which assessment would be the most important in deciding to release the client against medical advice (AMA)?
Potential danger to self or others
Bob is admitted for 96hrs. The nurse reviews the routine admission lab and medication prescriptions and notes that the client will resume the Prolixin. The Cogentin has not been prescribed. Which nursing action is best?
Obtain a prescription to begin the Cogentin ~ it will help prevent some of the extrapyramidal side effects of the prolixin
Which side effects would the nurse most likely observe with Prolixin, a traditional antipsychotic?
High extrapyramidal effects, low anticholinergic effects
The nurse asks Bob is he has any allergies to meds. He reports an allergy to Haldol. “My neck got real stiff, and I couldn’t move it”. What type of reaction should the nurse suspect?
Dystonia ~ acute, tonic muscle spasms ~ sometimes occur during the first few days of antipsychotic administration
Reassessment by the nurse indicates that he remains suspicious and guarded with orientation only to day and place. Bob believes he is a famous movie star and explains to the nurse that a limo driver will be there to get him later in the day. How should the nurse respond?
It sounds like you are anxious to leave here ~ respond to underlying feelings to encourage discussion of feelings
How should the nurse interpret Bob’s belief that he is a famous movie star and that a limo driver will arrive to get him later?
In planning his care, what’s the most important short-term client outcome?
Interact without expressing delusional thoughts
During reassessment, the nurse notices that Bob sometimes pauses and mumbles something quietly to himself. He tilts his head to one side and then returns his attention to the nurse. What is the best response by the nurse?
“Have you been hearing any voices?”
On the third day of hospitalization, the nurse must assign Bob to one of the unit groups. Which group will be most therapeutic?
Structured med group ~ schizophrenia patients have concrete thinking processes and will repond best to structured activities
Bob agrees to participation. He remains attention and responds to questions when asked. During the first group he shares, “The meds cause too many side effects. I have been taking them for a long time.” Which nursing problem should the nurse document for the group progress note?
Risk for adherence ~ if he perceives that the med has too many side effects, he may choose to stop taking it
The following week another client in the group asks the nurse-leader why individuals develop schizophrenia. Which understanding is most accurate?
This brain disorder has many predisposing factors and a biological basis
Since most of the people in the group have schizophrenia, the nurse leader decides to talk about symptom triggers in the last group session. How should the nurse explain symptom triggers to the clients?
Symptom triggers can be related to health, the environment, or attitudes ~ nutrition, lack of sleep, fatigue, housing difficulties, changes in life events, and feeling overpowered
One asks, “Why do you need to know about symptom triggers?” Which explain is best?
Knowing symptom triggers and how to manage them can help prevent relapse
After 3 weeks of hospitalization, Bob continues to be delusional and to talk to himself. The nurse often finds him sitting alone in the dining area. He declines some of the group activities and sits for several hours without initiating any activity. Persistent nursing interventions are required to get Bob to perform routine tasks. Which nursing assessment accurately describes Bob’s lack of energy?
Avolition ~ lack of energy or drive
Which nursing problem should be included on the treatment plan?
Bob’s healthcare provider decides to discontinue Prolixin and begins a new antipsychotic, Zyprexa. Which data is most important to obtain before Bob begins the Zyprexa, which is an atypical antipsychotic?
Baseline weight ~ weight gain occurs with atypical antipsychotics
Which side effects are characteristic of atypical antipsychotics?
-Fewer extrapyramidal effects
The nurse understands that an atypical antipsychotic requires what period of time to reach a steady state?
Which medication with potentially life-threatening side effects should the nurse expect the healthcare provider to prescribe for clients who do not respond to the use of other antipsychotics?
After several weeks, Bob begings to demonstrate more initiative to attend daily groups without prompting by the nurse. He awakens in the morning for the community meeting but continues to answer questions only when asked. Answers are simple, one-word answers without any elaboration. Which speech process should the nurse document on the daily mental status exam record?
poverty of speech
When the nurse asks Bob to share one goal for the day in community meeting, he states, “I’m going to take a shower and …” He pauses for several seconds and begins talking again. Which thought process does this exemplify?
thought blocking ~ sudden stopping in the client’s train of thought or in the middle of a sentence
The nurse further assesses Bob’s mental status to determine if he still has thoughts about FBI agents spying on him and hiding cameras in his apartment. The long-term goal is that Bob will not experience delusional thoughts by discharge. Which invention will best assess if this goal has been met?
Talk to Bob for at least 20 minutes
Because Bob was violent with his father prior to admission, another long-term goal is that the client will not verbalize the desire to harm self or others. Which statement will assist the nurse to assess if this goal has been met?
Do you think about hurting anyone now?
Bob talks to the nurse for nearly 30 mins without mentioning FBI agents in his apartment. When the nurse asks him about plans for discharge, Bob states that he wants to return to his apartment. He denies having any thoughts of hurting himself or others. The treatment team meets to review Bob’s discharge plan and response to the new atypical antipsychotic. The discharge plan is to dismiss Bob in 1 week. A criterion for discharge is that Bob will attend a weekly wellness group. What will be the most important group activity to promote wellness in the community?
Explore symptom management
What is the first step the nurse should teach about effective symptom management?
ID problem symptoms
After implementing the first step, what step is taken next?
ID current ways to manage symptoms
One of the behavioral interventions that the nurse plans to teach the clients is ways to cope with symptos such as hallucinations and delusions. Which strategy is best for clients who hear voices?
Avoid certain situations
The nurse plans to talk about relapse prevention. What is the most common cause of relapse in the client with schizophrenia?
A client in the wellness group states that he was taking his meds every day and started hearing voices more and had to be hospitalized. What is the nurse’s best response?
This can happen even if you are taking meds every day
Bob’s community case worker has been contacted about the discharge plans and the need for transportation to Bob’s apartment. What is the greatest benefit of a case worker for this client?
Coordinate services for Bob