question

Meet the client:

answer

Bob Tyler, a 40-year-old male, is brought to the emergency department by the police after being violent with his father. Bob has multiple past hospitalizations and treatment for schizophrenia. Bob believes that the healthcare providers are FBI agents and his apartment is a site for slave trading. He believes that the FBI has cameras in his apartment to monitor his moves and broadcast them on TV.

question

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

answer

Establish rapport and trust.

question

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?

answer

Delusions.

question

Which behavior is characteristic of a thought disorder?

answer

Disorganized speech.

question

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

answer

Negative symptoms. (minimal eye contact, poor grooming and hygiene, and apathy)

question

Which finding depicts negative symptoms of schizophrenia?

answer

Flat affect and social inattentiveness.

question

Which nursing problem has priority?

answer

Disturbed thought processes.

question

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

answer

Disorganized thoughts.

question

The nurse understands that a client with schizophrenia will experience which benefit from fluphenazine decanoate (Prolixin) if it is administered intramuscularly?

answer

Maintain long-term medication compliance.

question

Which client behavior validates the need for involuntary hospitalization?

answer

Violence towards father.

question

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)?

answer

Potential danger to self or others.

question

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?

answer

Obtain a prescription to begin the Cogentin.

question

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

answer

High extrapyramidal effects, low anticholinergic effects.

question

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?

answer

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

question

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?

answer

"It sounds like you are anxious to leave here."

question

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?

answer

Delusional thoughts.

question

In planning this client's care, what is the most important short-term client outcome?

answer

Interact without expressing delusional thoughts.

question

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?

answer

"Have you been hearing any voices?"

question

Which group will be most therapeutic for Bob?

answer

Structured medication group.

question

"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?

answer

Risk for adherence.

question

The following week another client in the group asks the nurse-leader why individuals develop schizophrenia. Which understanding is most accurate?

answer

This brain disorder has many predisposing factors and a biological basis.

question

How should the nurse explain symptom triggers (of schizophrenia) to the clients?

answer

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)

question

One client in the group asks, "Why do we need to know about symptom triggers?" Which explanation is best?

answer

"Knowing symptom triggers and how to manage them can help prevent relapse."

question

Which nursing assessment accurately describes Bob's lack of energy?

answer

Avolition. (lack of energy or drive)

question

Which nursing problem should be included on the treatment plan?

answer

Social isolation.

question

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

answer

Baseline weight.

question

Which side effects are characteristic of atypical antipsychotics?

answer

Fewer extrapyramidal effects.

question

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

answer

1 week.

question

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?

answer

Clozapine (Clozaril).

question

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?

answer

Poverty of speech.

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?

answer

Thought blocking.

question

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?

answer

Talk to Bob for at least 20 minutes.

question

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?

answer

"Do you think about hurting anyone now?"

question

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

answer

Explore symptom management.

question

What is the first step the nurse should use to teach about effective symptom management?

answer

Identify problem symptoms.

question

After implementing the first step, what step is taken next?

answer

Identify current ways to manage symptoms.

question

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?

answer

Avoid certain situations.

question

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

answer

Medications.

question

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?

answer

"This can happen even if you are taking medications every day."

question

What is the greatest benefit of a case worker for this client?

answer

Coordinate services for Bob.

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