HESI Case Study: Schizophrenia Sam
Harris Based on this assessment, what is the most important nursing intervention?Establish rapport and trust.Assess for hallucinations.Maintain adequate social space.Plan to give a PRN antipsychotic. - ANSWER Establish rapport and trust The most important intervention for a client who is suspicious and guarded is to 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 that there are cameras in his apartment to monitor his moves?Hallucinations.Delusions.Confabulation.Thought broadcasting. - ANSWER Delusions Delusions are fixed, false beliefs that the nurse should avoid trying to logically disprove to the client. 1 / 3
Which behavior is characteristic of a thought disorder?Blunted affect.Irritability.Lability of mood.Preoccupation with guilty feelings. - ANSWER Blunted affect A blunted or flat affect can occur as part of the negative or "soft" symptoms associated with a thought disorder. It can also occur with a mood disorder.Mental Status Exam The nurse completes the mental status exam and records that Sam's grooming and hygiene are fair. Sam 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 blase'. His affect is anxious, and his facial expression is blunted. He is inattentive and appears distracted. - ANSWER The nurse understands that schizophrenia can be differentiated from psychosis by which assessment?Disorganized speech.Disorganized behavior.Auditory hallucinations.Negative symptoms. - ANSWER Negative symptoms Negative symptoms are characteristic of schizophrenia and include behaviors such as minimal eye contact, poor grooming and hygiene, and apathy.Which finding depicts negative symptoms of schizophrenia? 2 / 3
Difficulty sitting still.Rapid and disorganized speech.Flat affect and social inattentiveness.Delusional statements. - ANSWER Flat affect and social inattentiveness Flat affect and social inattentiveness, or "spaciness," are examples of negative symptoms characteristic of schizophrenia.Which nursing problem has priority?Ineffective community coping.Disturbed thought processes.Sensory-perceptual disturbance.Ineffective denial. - ANSWER Disturbed thought processes Disturbed thought processes is a priority problem because Sam is delusional.Medications Sam is unable to report his current medication regimen, so the nurse contacts his case worker to find out what medications Sam is taking. Additional information from the case worker indicates that Sam has been sleeping only 3 to 4 hours each night for the past few nights. Sam has demonstrated less energy and states that he feels really bad and pretty down. The case worker reports that Sam was taking fluphenazine (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). - ANSWER What is the reason that Prolixin is prescribed for this patient?
- / 3