Schizophrenia Case Study

The nurse assesses that Bob’s behavior is guarded and suspicious. Based on this assessment, what is the most important nursing intervention?
Establish rapport and trust.

when clients have cognitive disorders and difficulty processing language the beginning of trust is more readily established through nonverbal communication

What is the most accurate assessment if the client believes that the healthcare providers are FBI agents and there are cameras in his apartment to monitor his moves?

delusions are fixed, false beliefs that the nurse should avoid trying to logically disprove to the client

Which behavior is characteristic of a thought disorder?
Disorganized speech.

it is the manifestation of disorganized thoughts.

mental status exam: grooming and hygiene are fair. he continually paces in the hall and is unable to sit still for longer than 1-2 minutes. speech is rapid and difficult to follow. he describes his mood as “biase.” his affect is anxious, and his facial expression is flat with a blank smile. he is inattentive and appears distracted.

The nurse understands that schizophrenia can be differentiated from psychosis by which assessment?

Negative symptoms.

(minimal eye contact, poor grooming and hygiene, and apathy)

Which finding depicts negative symptoms of schizophrenia?
Flat affect and social inattentiveness.

flat affect and social inattentiveness, or “spaciness,” are examples of negative symptoms characteristic of schizophrenia.

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Which nursing problem has priority?
Disturbed thought processes.

disturbed thought processes is a priority problem because Bob is delusional

Bob is unable to report his current medication regimen, so the nurse contacts his case worker to find out what medication Bob is taking. Additional information from the case worker indicates that Bob has been sleeping only 3-4 hours 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 fluphenazine (Prolixin) 5mg in the morning and 10mg at bedtime, along with benztropine (Congentin) 2mg BID because he cannot afford the newer antipsychotics such as olanzapene (Zyprexa)

What is the reason that Prolixin is prescribed for this client?

Disorganized thoughts.

antipsychotic medications are useful to manage symptoms related to cognitive impairment such as delusions and/or hallucinations, as well as behaviors related to agitation and aggression.

The nurse understands that a client with schizophrenia will experience which benefit from fluphenazine (Prolixin) if it is administered intramuscularly?
Maintain long-term medication compliance.

prolixin is a long-acting medication that is administered as an injection every 7-28 days to promote compliance with the medication regimen.

Bob refuses treatment and wants to leave the emergency department. The client is admitted involuntarily for 96 hours.

Which client behavior validates the need for involuntary hospitalization?

Violence towards father.

risk for violence toward self or others is a criterion for involuntary hospitalization

after 96 hours of involuntary commitment, a client must be asked to sign consent for hospitalization.

If a client who has voluntarily chosen to be hospitalized should want to leave the hospital, which assessment would be most important in deciding to release the client against medical advice (AMA)?

Potential danger to self or others.

response to medication is important to consider as it related to the client’s mental status, but it is not most important consideration for releasing the client AMA

Bob is admitted to the mental health unit for 96 hours.
The nurse reviews the routine admission lab and medication prescriptions, and notes that the client will resume the fluphenazine decanoate (Prolixin). The benztropine (Cogentin) has not been prescribed.

Which nursing action is best?

Obtain a prescription to begin the Cogentin.

the nurse should request a prescription for congentin, which will help prevent the extrapyramidal side effects of the prolixin, with the exception of tardive dyskinesia. there is a risk of decreased efficiency of prolixin when the client is also taking congentin.

Which side effects would the nurse most likely observe with fluphenazine decanoate (Prolixin), a traditional antipsychotic?
High extrapyramidal effects, low anticholinergic effects.

traditional antipsychotics generally have high extrapyramidal effects and low anticholinergic effects

The nurse asks Bob if he has any allergies to medications. He reports an allergy to haloperidol (Haldol). The nurse asks him to describe the type of reaction he experienced. Bob states, “My neck got real stiff, and I couldn’t move it.”

What type of reaction should the nurse suspect?


(acute, tonic muscle spasms, often of the tongue, jaw, eyes, and neck, but sometimes of the whole body)

In addition to Bob’s thoughts that the FBI had cameras in his apartment and his moves were broadcast on TV, reassessment by the nurse indicates that he remains suspicious and guarded with orientation only to day and place. Bob believes that he is a famous movie star and explains to the nurse that a limousine 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.”

responding to the underlying feelings rather than the illogical content of the delusion will encourage discussion of fears, anxiety, and anger about hospitalization, without assuming that the delusion is right or wrong

How should the nurse interpret Bob’s belief that he is a famous movie star, and a limousine driver will arrive to get him later in the day?
Delusional thoughts.

the client’s thoughts are delusional because he has false beliefs about being a movie star and that a limousine will pick him up

In planning this client’s care, what is the most important short-term client outcome?
Interact without expressing delusional thoughts.

when a client is delusional, interacting w/o expressing delusional thoughts is an important short-term outcome. as the client gains insight into the symptoms, the client can differentiate experiences with delusions from those that are reality.

During reassessment of the client, 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?”

when the client tilts his head to one side, it is a nonverbal cue that he is hearing voices. the nurse should assess for the presence of auditory hallucinations.

on the 3rd day of hospitalization, the nurse must assign Bob to one of the unit groups.

Which group will be most therapeutic for Bob?

Structured medication group.

a structured medication group will be most therapeutic because clients w schizophrenia have concrete thinking processes and will respond best to structured activities. Groups that support medication education are important to promote medication compliance.

“The medications cause too many side effects. I have been taking them for a long time.”

Based on Bob’s statement, which nursing problem should the nurse document for the group progress note?

Risk for adherence.

risk for adherence is evident because if the client perceives that the medication 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.

schizophrenia is a brain disorder with many predisposing factors. These factors include biological factors related to genetics, neurobiology, neurotransmitters, and neurodevelopment of structural, functional, and chemical brain changes that occur in early years of life and before birth.

How should the nurse explain symptom triggers (of schizophrenia) to the clients?
Symptom triggers can be related to health, the environment, or attitudes.

(These triggers can be related to nutrition, lack of sleep, fatigue, housing difficulties, changes in life events, and feeling overpowered)

One client in the group asks, “Why do we need to know about symptom triggers?” Which explanation is best?
“Knowing symptom triggers and how to manage them can help prevent relapse.”

a client can learn to cope w symptom triggers and prevent relapse and hospitalization

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?
Social isolation.

social isolation is manifested by behaviors such as the client sitting alone continuously w/o interacting w others

Which data is most important to obtain before Bob begins the Zyprexa, which is an atypical antipsychotic?
Baseline weight.

weight gain occurs w the atypical antipsychotics, especially zyprexa (olanzapine) and clozapine (clozaril)

Which side effects are characteristic of atypical antipsychotics?
-fewer extrapyramidal effects

-dry mouth: anticholinergic side effects such as dry mouth, blurred vision, urinary hesitancy and constipation are commonly experienced w atypical antipsychotics

The nurse understands that an atypical antipsychotic like olanzapine (Zyprexa) requires what period of time to reach a steady state?
1 week.
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?
Clozapine (Clozaril).

when a client has failed to respond to antipsychotic medications or long-acting antipsychotics, clozapine (clozaril) may be initiated. clozaril is used for clients w schizophrenia who have not responded to other antipsychotics. the potentially serious side effect of agranulocytosis requires that WBC counts be done weekly or every 2 weeks.

Bob awakens in the morning for the community meeting, but continues to answer questions only when asked. Answers to questions 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.

a client who demonstrates poverty of speech gives simple one- or two-word answers to questions, even when the nurse asks an open-ended question.

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

thought blocking is the 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 intervention by the nurse will best assess if this goal has been met?

Talk to Bob for at least 20 minutes.

the nurse should be able to talk to the client w/o observing the presence of delusional thoughts

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?”

the nurse should directly ask the client about thoughts of harm

What will be the most important group activity to promote wellness in the community?
Explore symptom management

symptom management exploration is an important activity for clients w schizophrenia so that relapse can be prevented. Clients often continue to experience symptoms such as hallucinations while living in the community

What is the first step the nurse should use to teach about effective symptom management?
Identify problem symptoms.

identifying problem symptoms is the first step of effective symptom management

After implementing the first step, what step is taken next?
Identify current ways to manage symptoms.

after the client has identified problem symptoms, the client should then identify current symptom management techniques and specific support systems and discuss other ways to manage symptoms

One of the behavioral interventions that the nurse plans to teach the clients is ways to cope with symptoms such as hallucinations and delusions.

Which strategy is best for clients who hear voices?

Avoid certain situations.

avoiding situations that increase symptoms can be helpful to minimize symptoms. other general strategies include distraction, help seeking, or attempts to feel better such as taking a shower or performing relaxation exercise

The nurse plans to talk about relapse prevention.

What is the most common cause of relapse in the client with schizophrenia?


the most common cause of relapse relate in some way to medications. relapse is likely to occur whether the client is taking medications or not, especially if the client has poor health practices

A client in the wellness group states that he was taking his medications 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 medications every day.”

the nurse should explain that relapse can occur even if the client has been taking meds as prescribed

What is the greatest benefit of a case worker for this client?
Coordinate services for Bob.

greatest benefit of the case worker is to coordinate services related to housing, finances, and medical appointments, for example.

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