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.
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 assessment, what is the most important nursing intervention? A) Establish rapport and trust.
The most important intervention for a client who is suspicious and guarded is to establish rapport and trust. The beginning of trust is more readily established through nonverbal communication when clients have cognitive disorders and difficulty processing language. 2.
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? B) Delusions.
Delusions are fixed, false beliefs that the nurse should avoid trying to logically disprove to the client. The nurse understands that Bob has a thought disorder rather than a mood disorder. Thought disorders include psychosis and schizophrenia. 3.
Which behavior is characteristic of a thought disorder?
C) Disorganized speech.
Disorganized speech is characteristic of thought disorders. It is the manifestation of disorganized thoughts.
Mental Status Exam
The nurse completes the mental status exam and records that Bob’s grooming and hygiene are fair. Bob continually paces in 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 “blasé.” 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? D) Negative symptoms.
Negative symptoms are characteristic of schizophrenia and include behaviors such as minimal eye contact, poor grooming and hygiene, and apathy. 5.
Which finding depicts negative symptoms of schizophrenia?
C) Flat affect and social inattentiveness.
Flat affect and social inattentiveness, or ‘spaciness’, are examples of negative symptoms characteristic of schizophrenia. 6.
Which nursing problem has priority?
B) 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 medications 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 decanoate (Prolixin) 5 mg in the morning and 10 mg at bedtime, along with benztropine (Cogentin) 2 mg BID because he cannot afford the newer antipsychotics such as olanzapene (Zyprexa). 7.
What is the reason that Prolixin is prescribed for this client? A) 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. 8.
The nurse understands that a client with schizophrenia will experience which benefit from fluphenazine decanoate (Prolixin) if it is administered intramuscularly? B) 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.
Legal Issue: Involuntary Admission
Bob refuses treatment and wants to leave the Emergency Department. The client is admitted involuntarily for 96 hours.
9. Which client behavior validates the need for involuntary hospitalization? C) Violence towards father.
Risk for violence towards self or others are criteria for involuntary hospitalization. Guarded and suspicious behaviors do not justify involuntary hospitalization. After 96 hours of involuntary commitment, a client must be asked to sign consent for hospitalization. 10.
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)? D) Potential danger to self
Potential for harm to self and others is the most important assessment in deciding to release 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?
A) Obtain a prescription to begin the Cogentin.
The nurse should request a prescription for Cogentin, 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 Cogentin.
12. Which side effects would the nurse most likely observe with fluphenazine decanoate (Prolixin), a traditional antipsychotic? A) High extrapyramidal effects, low anticholinergic effects. CORRECT
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.”
13. What type of reaction should the nurse suspect?
Dystonia is acute, tonic muscle spasms, often of the tongue, jaw, eyes, and
neck, but sometimes of the whole body. These spasms sometimes occur during the first few days of antipsychotic administration.
Delusional Thoughts and Hallucinations
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.
14. How should the nurse respond?
D) “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.
15. 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? B) Delusional thoughts.
The client’s thoughts are delusional because he has false beliefs about being a movie star, and believes that a limousine will pick him up.
16. In planning this client’s care, what is the most important short-term client outcome? A) Interact without expressing delusional thoughts.
When a client is delusional, interacting without 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.
17. What is the best response by the nurse?
C) “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. Bob smiles at the nurse, but refuses to answer.
On the third day of hospitalization, the nurse must assign Bob to one of the unit groups. 18.
Which group will be most therapeutic for Bob?
A) Structured medication group.
A structured medication group will be most therapeutic because clients with schizophrenia have concrete thinking processes and will respond best to structured activities. Groups that support medication education are important to promote medication compliance. Bob agrees to participate in a group that is scheduled to last for 3 weeks. He remains attentive and responds to questions when asked. During the first group he shares, “The medications cause too many side effects. I have been taking them for a long time.”
19. Based on Bob’s statement, which nursing problem should the nurse document for the group progress note? D) 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.
Causes and Symptom Triggers
The following week another client in the group asks the nurse-leader why individuals develop schizophrenia. 20.
Which understanding is most accurate?
D) This brain disorder has many predisposing factors and a biological basis. CORRECT
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. Since most of the clients in the group have schizophrenia, the nurse-leader decides to talk about symptom triggers in the last group session. 21.
How should the nurse explain symptom triggers to the clients? B) Symptom triggers can be related to health, the environment, or attitudes. CORRECT
Symptom triggers are stimuli, or combinations of stimuli, and stressors that precede a new episode of the illness. These triggers can be related to nutrition, lack of sleep, fatigue, housing difficulties, changes in life events, and feeling overpowered, for example. One client in the group asks, “Why do we need to know about symptom triggers?” 22.
Which explanation is best?
A) “Knowing symptom triggers and how to manage them can help prevent relapse.” CORRECT
A client can learn to cope with symptom triggers and prevent relapse and hospitalization.
Negative Symptoms of Schizophrenia
After 3 weeks of hospitalization, Bob continues to be delusional and 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. Performing routine tasks requires persistent nursing interventions. 23.
Which nursing assessment accurately describes Bob’s lack of energy? C) Avolition.
Avolition is a lack of energy or drive.
24. Which nursing problem should be included on the treatment plan? B) Social isolation.
Social isolation is manifested by behaviors such as the client sitting alone continuously without interacting with others.
Bob’s healthcare provider decides to discontinue the fluphenazine decanoate (Prolixin) and begin a new antipsychotic, olanzapine (Zyprexa). Bob’s case worker is contacted and financial arrangements are made for Bob to receive the Zyprexa.
Which data is most important to obtain before Bob begins the Zyprexa, which is an atypical antipsychotic? A) Baseline weight.
Weight gain occurs with the atypical antipsychotics, especially Zyprexa (olanzapine) and clozapine (Clozaril). The nurse recalls that the atypical antipsychotics have different side effects than traditional antipsychotics. 26.
Which side effects are characteristic of atypical antipsychotics? C) Fewer extrapyramidal effects.
Atypical antipsychotics have less extrapyramidal effects.
27. The nurse understands that an atypical antipsychotic like olanzapine (Zyprexa) requires what period of time to reach a steady state? C) 1 week.
Steady state is generally reached in 1 week.
The nurse is hopeful that Bob will respond favorably to the new antipsychotic. The nurse recalls that another client with schizophrenia was treated with olanzapine (Zyprexa) without a positive response. When that
client failed to respond, several other atypical antipsychotics were given to manage the client’s symptoms.
28. 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? A) 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 with schizophrenia who have not responded to other antipsychotics. The potentially serious side effect of agranulocytosis requires that weekly, or every 2-week WBC counts be done.
Speech and Thought Processes
After several weeks, Bob begins 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 to questions are simple, one-word answers without any elaboration. 29.
Which speech process should the nurse document on the daily mental status exam record? D) Poverty of speech.
A client who demonstrates poverty of speech demonstrates 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. 30.
Which thought process does this exemplify?
D) Thought blocking.
Thought blocking is the sudden stopping in the client’s train of thought or
in the middle of a sentence. Evaluation of Goal Achievement
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. 31.
Which intervention by the nurse will best assess if this goal has been met? B) Talk to Bob for at least 20 minutes.
The nurse should be able to talk to the client without 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.
32. Which statement will assist the nurse to assess if this goal has been met? D) “Do you think about hurting anyone now?”
The nurse should directly ask the client about thoughts of harm.
Symptom Management Techniques
Bob talks to the nurse for nearly 30 minutes 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 the client in 1 week. A criterion for discharge is that Bob will attend a weekly wellness group.
33. What will be the most important group activity to promote wellness in the community? A) Explore symptom management.
Symptom management exploration is an important activity for clients with schizophrenia so that relapse can be prevented. Clients often continue to experience symptoms such as hallucinations while living in the community. The nurse plans to teach the group members about symptom management techniques. 34.
What is the first step the nurse should use to teach about effective symptom management? C) Identify problem symptoms.
Identifying problem symptoms is the first step of effective symptom management. 35.
After implementing the first step, what step is taken next?
A) Identify current ways to manage symptoms.
After the client has identified problem symptoms, the client should then identify current symptom management techniques, 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.
36. Which strategy is best for clients who hear voices?
A) 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 relaxation exercises. Relapse Prevention
The nurse plans to talk about relapse prevention.
37. What is the most common cause of relapse in the client with schizophrenia? B) Medications.
The most common causes 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. 38.
What is the nurse’s best response?
A) “This can happen even if you are taking medications every day.” CORRECT
The nurse should explain that relapse can occur even if the client has been taking medications as prescribed. One week later Bob has achieved the long-term goal to be free of delusions, and he has attended the wellness group to promote wellness in the community. Bob’s community case worker has been contacted about the discharge plans and need for transportation to Bob’s apartment. 39.
What is the greatest benefit of a case worker for this client? A) Coordinate services for Bob.
The greatest benefit of the case worker is to coordinate services related to housing, finances, and medical appointments, for example.
Bob returns to his apartment. He continues to attend the wellness group. He shares with his case worker that he is not happy with the weight he has gained, but for the present is willing to remain on his medication.