Schizophrenia Answer Key

1. The most commonly supported neuroanatomic theory of schizophrenia suggests which etiology? A) Excessive amounts of dopamine and serotonin in the brain B) Ineffective ability of the brain to use dopamine and serotonin C) Insufficient amounts of dopamine in the brain D) Decreased brain tissue in the frontal and temporal regions of the brain Ans: D Feedback: Decreased brain tissue in the frontal and temporal regions of the brain is the most commonly supported neuroanatomic theory that suggests the etiology of schizophrenia. The other theories are neurochemical. 2. The nurse reviews current literature and identifies that which of the following are included in current studies of biologic theories regarding the etiology of schizophrenia? Select all that apply. A) That there is a particular pathologic structure associated with the disease. B) That genetics is the cause of schizophrenia. C) Persons with schizophrenia have decreased brain volume and abnormal brain function in the frontal and temporal areas of persons with schizophrenia. D) The brain activity of persons with schizophrenia differs from people who do not have schizophrenia. E) That the etiology of schizophrenia may be related to the body's response to exposure of a virus. Ans: B, C, D, E Feedback: In the first half of the 20th century, studies focused on trying to find a particular pathologic structure associated with the disease, largely through autopsy. Such a site was not discovered. The biologic theories of schizophrenia focus on genetic factors, neuroanatomic and neurochemical factors (structure and function of the brain), and immunovirology (the body's response to exposure to a virus). 3. The student nurse correctly recognizes that which one of the following findings is best supported by genetic studies in the etiology of schizophrenia? A) If a person has schizophrenia, distant relatives are also at risk. B) That there is no relationship at all between schizophrenia and genetics. C) That there is a weak correlation between genetics and schizophrenia. D) That schizophrenia is at least partially inherited. Ans: D Feedback: The most important studies have centered on twins; these findings have demonstrated that if one identical twin has schizophrenia, the other twin has a 50% chance of developing it as well. Fraternal twins have only a 15% risk. This finding indicates that schizophrenia is at least partially inherited. Page 1 4. The nurse is assessing for negative symptoms of schizophrenia in a newly admitted client. The nurse would note which behavior as indicative of a negative symptom? A) Difficulty staying on subject when responding to assessment questions B) Belief of owning a transportation device allowing for travel to the center of the Earth C) Hesitant to answer the nurse's questions during the assessment interview D) Mimicking the postural changes made by the nurse during the assessment interview Ans: C Feedback: A negative symptom of schizophrenia is alogia, or the tendency to speak very little or to convey little substance of meaning (poverty of content). Associative looseness (fragmented or poorly related thoughts and ideas), delusions (fixed false beliefs that have no basis in reality), and echopraxia (imitation of the movements and gestures of another person whom the client is observing) are all positive symptoms. 5. The client with schizophrenia believes the student nurses are there to spy on the clients. The client is suffering from which of the following symptoms? A) Hallucinations B) Delusions C) Anhedonia D) Ideas of reference Ans: B Feedback: Delusions are fixed false beliefs that have no basis in reality. Hallucinations are false sensory perceptions or perceptual experiences that do not exist in reality. Ideas of reference are false impressions that external events have special meaning for the person. Anhedonia is feeling no joy or pleasure from life or any activities or relationships. Page 2 6. The client with schizophrenia makes the following statement, ìI just don't know how to count. The sky turned to fire. I have a ball in my head.î The nurse documents this entire statement as an example of A) flight of ideas. B) ideas of reference. C) delusional thinking. D) associative looseness. Ans: D Feedback: Associative looseness is demonstrated through fragmented or poorly related thoughts and ideas. The series of disconnected thoughts best exemplifies this concept. Some of the statements contain delusions, or fixed false beliefs that have no basis in reality. Flight of ideas refers to rapidly flowing thoughts that are more connected than the client's statement. Ideas of reference are false impressions that external events have special meaning for the person. 7. A person suffering from schizophrenia has little emotional expression when interacting with others. The nurse would document the client's affect as which of the following? Select all that apply. A) Flat B) Blunt C) Bright D) Inappropriate E) Pleasant Ans: A, B Feedback: Clients with schizophrenia are often described as having blunted affect (few observable facial expressions) or flat affect (no facial expression). The client may exhibit an inappropriate expression or emotions incongruent with the context of the situation. It is not likely that the affect of a person with schizophrenia would be pleasant. Page 3 8. A client who has schizophrenia is having a conversation with the nurse suddenly stops talking in the middle of a sentence. The client is experiencing which type of thought disruption? A) Thought withdrawal B) Thought insertion C) Thought blocking D) Thought broadcasting Ans: C Feedback: The nurse can assess thought content by evaluating what the client actually says. For example, clients may suddenly stop talking in the middle of a sentence and remain silent for several seconds to 1 minute (thought blocking). They also may state that they believe others can hear their thoughts (thought broadcasting), that others are taking their thoughts (thought withdrawal), or that others are placing thoughts in their mind against their will (thought insertion). 9. During the nursing assessment, a client describes constantly hearing voices mumbling in the background. The client denies that the voices are telling him to do anything harmful. The nurse documents that the client is experiencing which of the following? A) Command hallucinations B) Auditory hallucinations C) Olfactory hallucinations D) Gustatory hallucinations Ans: B Feedback: Auditory hallucinations, the most common type, involve hearing sounds, most often voices, talking to or about the client. Command hallucinations are voices demanding that the client take action, often to harm self or others, and are considered dangerous. Olfactory hallucinations involve smells or odors. Gustatory hallucinations involve a taste lingering in the mouth or the sense that food tastes like something else. Page 4 10. A client with schizophrenia reads the advice column in the newspaper daily. When asked why the client is so interested in the advice column, the client replies, ìThis person is my guide and tells me what I must do every day.î The nurse would best describe this type of thinking as which of the following? A) Referential delusion B) Grandiose delusion C) Thought insertion D) Personalization Ans: A Feedback: Referential delusions or ideas of reference involve the client's belief that television broadcasts, music, or newspaper articles have special meaning for him or her. Grandiose delusions are characterized by the client's claim to association with famous people or celebrities, or the client's belief that he or she is famous or capable of great feats. Thought insertion is the belief that others are placing thoughts in their mind against their will. Personalization is not a psychotic characteristic of schizophrenia. 11. The nurse is preparing a client with schizophrenia for discharge. The nurse asks the client, ìHow are you going to care for yourself at home?î The purpose of the nurse's question is to assess the client's A) self concept. B) judgment. C) insight. D) social support system. Ans: C Feedback: Insight refers to the client's degree of self-awareness and realistic view of life. It can be severely impaired in schizophrenia. Over time, some clients can learn about the illness, anticipate problems, and seek appropriate assistance as needed. Judgment refers to appropriate decision-making ability and is based on the ability to interpret the environment correctly. At times, lack of judgment is so severe that clients cannot meet their needs for safety and protection and place themselves in harm's way. Page 5 12. All of the following are nursing diagnoses identified for a client with schizophrenia. The student nurse correctly anticipates which diagnosis will resolve when the client's negative symptoms improve? A) Impaired verbal communication B) Risk for other-directed violence C) Disturbed thought processes D) Social isolation Ans: D Feedback: NANDA diagnoses commonly established based on the assessment of psychotic symptoms or positive signs are as follows: - Risk for other-directed violence - Risk for suicide - Disturbed thought processes - Disturbed sensory perception - Disturbed personal identity - Impaired verbal communication NANDA diagnoses based on the assessment of negative signs and functional abilities include the following: - Self-care deficits - Social isolation - Deficient diversional activity - Ineffective health maintenance - Ineffective therapeutic regimen management 13. All of the following are included in the plan of care for a client with schizophrenia. Which nursing intervention should the nurse perform first when caring for this client? A) Observe for signs of fear or agitation B) Maintain reality through frequent contact C) Encourage to participate in the treatment milieu D) Assess community support systems Ans: A Feedback: Safety for both the client and the nurse is the priority when providing care for the client with schizophrenia. The nurse must observe for signs of building agitation or escalating behavior such as increased intensity of pacing, loud talking or yelling, and hitting or kicking objects. The nurse must then institute interventions to protect the client, nurse, and others in the environment. Page 6 14. A client with schizophrenia is seen sitting alone and talking out loud. Suddenly, the client stops and turns as if listening to someone. The nurse approaches and sits down beside the client. Which of the following is the best initial response by the nurse? A) ìYou must be pretty bored to be sitting here talking to an invisible person.î B) ìI don't hear or see anyone else; what are you hearing and seeing?î C) ìI can tell you are hearing voices, but they are not real.î D) ìHow long have you known the person you are talking to?î Ans: B Feedback: Intervening when the client experiences hallucinations requires the nurse to focus on what is real and to help shift the client's response toward reality. Initially, the nurse must determine what the client is experiencingóthat is, what the voices are saying or what the client is seeing. In command hallucinations, the client hears voices directing him or her to do something, often to hurt self or someone else. For this reason, the nurse must elicit a description of the content of the hallucination so that health-care personnel can take precautions to protect the client and others as necessary. The nurse might say, ìI don't hear any voices; what are you hearing?î ìHow long have you known the person you are talking to?î would reinforce the client's hallucination. 15. A client states, ìI am dead. I have come back from the dead.î An appropriate response by the nurse is, A) ìWhat is it like to feel dead?î B) ìNo you did not die. People don't come back from the dead.î C) ìShow me what you did in art therapy this morning.î D) ìI'll get your medicine and you'll feel better.î Ans: C Feedback: The client experiencing delusions utterly believes them and cannot be convinced they are false or untrue. It is the nurse's responsibility to present and maintain reality by making simple statements. The nurse must avoid openly confronting the delusion or arguing with the client about it. The nurse also must avoid reinforcing the delusional belief by ìplaying alongî with what the client says. Page 7 16. A client diagnosed with schizophrenia is laughing and talking while sitting alone. Which of the following is the best response by the nurse? A) State, ìCan you share your joke with me?î B) To sit with the client quietly until the client is ready to talk C) State, ìTell me what's happening.î D) State, ìYou look lonely here. Let's join the others in the day room.î Ans: C Feedback: Having the client tell the nurse what is happening explores what the client is experiencing and engages the client in reality interaction. Answer choices A, B, and C are not appropriate responses by the nurse in this situation. 17. A college freshman is admitted to the hospital with a diagnosis of schizophrenia. Friends reported that she had been in her room for 2 days in a trance-like state, not eating nor speaking to anyone. Which of the following is the highest priority for this client? A) Assessing fluid intake and output B) Completing an assessment of mental status C) Obtaining more data about her college experiences D) Providing for adequate rest Ans: A Feedback: Physiologic homeostasis is a priority for this client. Completing an assessment of mental status, obtaining data about college experiences, and providing adequate rest are not the highest priority. 18. The client with schizophrenia tells the nurse that rats have started to eat his brain. The best response by the nurse would be, A) ìHave you discussed this with your physician?î B) ìHow could that be possible?î C) ìYou cannot have rats in your brain.î D) ìYou look OK to me.î Ans: A Feedback: This sounds like a new symptom, so talking with the physician is important; the client may need to have his medication reevaluated. ìHow could that be possible,î puts the client on the defensive. ìYou cannot have rats in your brain,î refers to the response as being unbelievable. ìYou look OK to me,î is inappropriate and not therapeutic. Page 8 19. A client who has suspicion has been placed in a room with a roommate. The night nurse reports that this client has been awake for the past 3 nights. The likely explanation for his wakefulness is which of the following? A) He is fearful of what his roommate might do to him while he sleeps. B) He is a light sleeper and unaccustomed to a roommate. C) He is watching for an opportunity to escape. D) He is worrying about his family problems. Ans: A Feedback: Clients who have suspicion trust no one and believe others are going to harm them. Being fearful of his roommate, being a light sleeper and unaccustomed to a roommate, and worrying about family problems would not be the most likely reasons why this client has been awake for the past three nights. The other explanations are not as likely. 20. A client with schizophrenia is reluctant to take his prescribed oral medication. The most therapeutic response by the nurse to this refusal is, A) ìI can see that you're uncomfortable now, so we can wait until tomorrow.î B) ìIf you refuse these pills, you'll have to get an injection.î C) ìWhat is it about the medicine that you don't like?î D) ìYou know you have to take this medicine for your own good.î Ans: C Feedback: Asking the client why he does not like his medication explores the client's reason for refusal, which is the first step in resolving the issue. The nurse must determine the barriers to compliance for each client. Threatening the client with an injection is assault. Waiting until tomorrow puts off the inevitable. Telling him it is for his own good is not the most therapeutic response in order to get the client to take his medication. 21. The nurse observes a client with schizophrenia sitting alone, laughing occasionally, and turning his head as if listening to another person. The nurse assesses this behavior to indicate that the client is experiencing auditory hallucinations and says, A) ìAre you hearing something?î B) ìIt's a beautiful day, isn't it?î C) ìWould you like to go to your room to talk?î D) ìWould you like to take some of your PRN medication?î Ans: A Feedback: Asking the client if he is hearing something validates the nurse's assessment and focuses on the client's experience. The other choices do not address the situation of the client experiencing auditory hallucinations at the present time. Page 9 23. The nurse enters the room of a client with schizophrenia the day after he has been admitted to an inpatient setting and says, ìI would like to spend some time talking with you.î The client stares straight ahead and remains silent. The best response by the nurse would be, A) ìI can see you want to be alone. I'll come back another time.î B) ìYou don't need to talk right now. I'll just sit here for a few minutes.î C) ìI've got some other things I can do now. I hope you'll feel like talking later.î D) ìYou would feel better if you would tell me what you're thinking.î Ans: B Feedback: This response indicates acceptance of the client and shows genuine interest in him, building rapport and trust. Initially, the client may tolerate only 5 or 10 minutes of contact at one time. Establishing a therapeutic relationship takes time, and the nurse must be patient. The nurse must maintain nonverbal communication with the client, especially when verbal communication is not very successful. This involves spending time with the client, perhaps through fairly length periods of silence. The presence of the nurse is a contact with reality for the client and also can demonstrate the nurse's genuine interest and caring to the client. The other choices are not consistent with what is therapeutic for the client. Page 10 24. One evening, a client with schizophrenia leaves his room and begins marching in the hall. When approached by the nurse, the client says, ìGod says I'm supposed to guard the area.î Which of the following responses would be best? A) ìI understand you hear a voice. You and I are the only ones in the hall, and I don't hear a voice.î B) ìThe voices are part of your illness, and they will leave in time.î C) ìThis guarding responsibility can make you tired. You rest for now, and I'll guard a while.î D) ìYou are just imagining these things. Do not pay any attention to the voices.î Ans: A Feedback: Acknowledging that the client hears a voice validates that the client's experience is real to him, while presenting reality. ìThe voices are part of your illness, and they will leave in time,î is not appropriate to the client's statement. ìThis guarding responsibility can make you tired. You rest for now, and I'll guard a while,î reinforces the client's delusion. ì'You are just imagining these things. Do not pay any attention to the voices,î does not deal with the patient in a serious manner. 25. When performing discharge planning for a client who has schizophrenia, the nurse anticipates barriers to adhering to the medication regimen. The nurse assesses which of the following as improving the likelihood that the client will follow the prescribed medication regimen? Select all that apply. A) Short-term memory intact B) History of missing appointments C) Receives monthly disability checks D) Walking is primary mode of transportation E) States location of pharmacy nearest his residence Ans: A, C, E Feedback: Sometimes clients intend to take their medications as prescribed but have difficulty remembering when and if they did so. They may find it difficult to adhere to a routine schedule for medications. Clients may have practical barriers to medication compliance, such as inadequate funds to obtain expensive medications, lack of transportation or knowledge about how to obtain refills for prescriptions, or inability to plan ahead to get new prescriptions before current supplies run out. Page 11 26. A client with schizophrenia is attending a follow-up appointment at the community mental health clinic. The client reports to the nurse, ìI stopped taking the antipsychotic medication because I can't get a hard-on with my girlfriend anymore.î Which of the following should the nurse recommend to enhance the client's well-being? A) ìIt sounds like that is a problem for you. Don't you still find her to be sexy enough?î B) ìSexual dysfunction is a temporary side effect and should get better once your body is used to the medication.î C) ìYou should avoid having sex with your girlfriend anyway. Do you really want her to get pregnant?î D) ìIt is important for you to take an antipsychotic medication. You may need a different type that will be less likely to affect your sexual functioning. I would like to call your physician about this.î Ans: D Feedback: Some side effects, such as those affecting sexual functioning, are embarrassing for the client to report, and the client may confirm these side effects only if the nurse directly inquires about them. This may require a call to the client's physician or primary provider to obtain a prescription for a different type of antipsychotic. 27. Which of the following questions would best help the nurse to evaluate the effectiveness of antipsychotic medications for a client who has schizophrenia? Select all that apply. A) Have the symptoms you were experiencing disappeared? B) If the symptoms have not disappeared, are you able to carry out your daily life despite the persistence of some psychotic symptoms? C) Are you committed to taking the medication as prescribed? D) Are you satisfied with your quality of life? E) Do you have access to community agencies that will help you to live successfully in this community? Ans: A, B, C, D Feedback: The client's perception of the success of treatment plays a part in evaluation. In a global sense, evaluation of the treatment of schizophrenia is based on the following: ï Have the client's psychotic symptoms disappeared? If not, can the client carry out his or her daily life despite the persistence of some psychotic symptoms? ï Does the client understand the prescribed medication regimen? Is he or she committed to adherence to the regimen? ï Does the client believe that he or she has a satisfactory quality of life? The question, ìDo you have access to community agencies that will help you to live successfully in this community?î is an appropriate question to ask to evaluate the plan of care but does not directly relate to antipsychotic medications. Page 12 28. A client with schizophrenia has returned to the clinic because of an increase in symptoms. The client reports he stopped taking his meds because he did not like the side effects. The nurse educates the client about managing uncomfortable side effects. Which of the following is included in the teaching plan? Select all that apply. A) Suck on hard candy as desired B) Spend at least 30 minutes outside in the sun daily C) Use stool softeners as needed D) Decrease the amount of daily fluid intake E) Maintain a balanced calorie-controlled diet Ans: A, C, E Feedback: Unwanted side effects are frequently reported as the reason clients stop taking medications. Interventions, such as eating a proper diet and drinking enough fluids, using a stool softener to avoid constipation, sucking on hard candy to minimize dry mouth, or using sunscreen to avoid sunburn, can help to control some of these uncomfortable side effects. 29. The nurse is working with a client with schizophrenia, disorganized type. It is time for the client to get up and eat breakfast. Which of the following statements by the nurse would be most effective in helping the client prepare for breakfast? A) ìI'll expect you in the dining room in 20 minutes.î B) ìIt's time to put your dress on now.î C) ìStay right there and I'll get your clothes for you.î D) ìWhy don't you stay here and I'll get your tray for you.î Ans: B Feedback: Clients with schizophrenia may have significant self-care deficits. The client needs clear direction, with tasks broken into small steps, to begin to participate in her own self-care. The other choices do not support the client effectively. ìI'll expect you in the dining room in 20 minutes,î is authoritarian and does not allow the client dignity. ìStay right here, and I'll get your clothes for you,î is also authoritarian and does not allow the client dignity. ìWhy don't you stay here and I'll get your tray for you,î is kinder but it robs the client of the opportunity to do for himself or herself as much as possible. Page 13 30. The parents of a young adult male who has schizophrenia ask how they can recognize when their son is beginning to relapse. The nurse teaches the family to look for which of the following? Select all that apply. A) Excessive sleeping B) Fatigue C) Irritability D) Increased inhibition E) Negativity Ans: B, C, E Feedback: Teaching the client and family members to prevent or manage relapse is an essential part of a comprehensive plan of care. This includes providing facts about schizophrenia, identifying the early signs of relapse, and teaching health practices to promote physical and psychological well-being. Early signs of relapse include impaired cause-and-effect reasoning, impaired information processing, poor nutrition, lack of sleep, lack of exercise, fatigue, poor social skills, social isolation, loneliness, interpersonal difficulties, lack of control, irritability, mood swings, ineffective medication management, low selfconcept, looking and acting different, hopeless feelings, loss of motivation, anxiety and worry, disinhibition, increased negativity, neglecting appearance, and forgetfulness. 31. A client asks the nurse upon discharge, ìWhat should I do if I forget to take my medicine?î The nurse should explain to the client which of the following? A) ìJust double the dose next time it is scheduled.î B) ìSkip that dose and resume your regular with the next dose.î C) ìDon't miss doses, or you will not maintain therapeutic drug levels.î D) ìIf you remember within 3 to 4 hours later than it is due, take it then. If you remember more than 4 hours after it was due, do not take that dose.î Ans: D Feedback: If a client forgets a dose of antipsychotic medication, advise the client to take it if the dose is only 3 to 4 hours late. If the missed dose is more than 4 hours late or the next dose is due, ask the client to omit the forgotten dose. Page 14 32. Which of the following are central components of a psychiatric rehabilitation and recovery program? Select all that apply. A) Working with clients to have an improved quality of life according to society's point of view B) Working with clients to manage their own lives C) Working with clients to make effective treatment decisions D) Working with clients to have an improved quality of life according to his or her point of view. E) Working with clients to diagnose their problem early Ans: B, C, D Feedback: Psychiatric rehabilitation has the goal of recovery for clients with major mental illness that goes beyond symptom control and medication management. Working with clients to manage their own lives, make effective treatment decisions, and have an improved quality of lifeófrom the client's point of viewóare central components of such programs. 33. A student nurse is having a first experience in an inpatient psychiatric unit and is frightened by the behaviors of the clients with schizophrenia. The student should take which of the following actions to deal with fear? A) Express fear to the psychiatrist during rounds B) Pretend to not be afraid C) Stay in an open area while talking with the clients D) Insist that the instructor accompanies the student at all times. Ans: C Feedback: The nurse also may be genuinely frightened or threatened if the client's behavior is hostile or aggressive. The nurse must acknowledge these feelings and take measures to ensure his or her safety. This may involve talking to the client in an open area rather than in a more isolated location or having an additional staff person present rather than being alone with the client. If the nurse pretends to be unafraid, the client may sense the fear anyway and feel less secure, leading to a greater potential for the client to lose personal control. It is not possible for the instructor to accompany the student at all times. Page 15 34. Which of the following attitudes would be best for the nurse when the client who has schizophrenia acts as though the nurse is not trustworthy or that his or her integrity is being questioned? A) That the client is correct and the nurse is not trustworthy B) That the client wants to insult the nurse C) That the client's behavior is a part of the illness D) That the nurse's actions have failed Ans: C Feedback: Suspicious or paranoid behavior on the client's part may make the nurse feel as though he or she is not trustworthy or that his or her integrity is being questioned. The nurse must recognize this type of behavior as part of the illness and not interpret or respond to it as a personal affront. The nurse must not take responsibility for the success or failure of treatment efforts or view the client's status as a personal success or failure. Page 16