Schizophrenia Case Study

Initial Assessment 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. 1. Based on this assessment, what is the most important nursing intervention? A) Establish rapport and trust. CORRECT: 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. B) Assess for hallucinations. INCORRECT: Assessing hallucinations is not the priority if the client is suspicious because he will question the nurse's intentions. C) Maintain adequate social space. INCORRECT: Maintaining adequate social space is important, as well as approaching the client with calmness and gentle eye contact, but this is not the most important intervention. D) Plan to give a PRN antipsychotic. INCORRECT: Giving a PRN antipsychotic is helpful to minimize the client's cognitive symptoms, but other nonpharmacologic interventions will take priority. 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? A) Hallucinations. INCORRECT: A hallucination is an alteration in sensory perception. Most hallucinations are auditory, then visual, gustatory, tactile, and olfactory, respectively. B) Delusions. CORRECT: Delusions are fixed, false beliefs that the nurse should avoid trying to logically disprove to the client. C) Confabulation. INCORRECT: Confabulation occurs more often with clients who have dementia and are trying to fill in memory gaps. D) Thought broadcasting. INCORRECT: Thought broadcasting occurs when the client believes that thoughts are being broadcast to the outside world. 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? A) Blunted affect. INCORRECT: Blunted affect is more commonly associated with a mood disorder. B) Irritability. INCORRECT: Irritability is more commonly associated with a mood disorder. C) Disorganized speech. CORRECT: Disorganized speech is characteristic of thought disorders. It is the manifestation of disorganized thoughts. D) Preoccupation with guilty feelings. INCORRECT: Preoccupation with guilty feelings is more commonly associated with a mood disorder.

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 "blas." His affect is anxious and his facial expression is flat with a blank smile. He is inattentive and appears "distracted." 4. The nurse understands that schizophrenia can be differentiated from psychosis by which assessment? A) Disorganized speech. INCORRECT: Disorganized speech is characteristic of both psychosis and schizophrenia. B) Disorganized behavior. INCORRECT: Disorganized behavior is characteristic of both psychosis and schizophrenia. C) Auditory hallucinations. INCORRECT: Hallucinations are characteristic of both psychosis and schizophrenia. D) Negative symptoms. CORRECT: 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? A) Difficulty sitting still. INCORRECT: Difficulty sitting still is not a negative symptom and may be related to akathisia, an extrapyramidal side effect. B) Rapid and disorganized speech. INCORRECT: Rapid and disorganized speech is not a negative symptom. Rapid speech is characteristic of flight of ideas. C) Flat affect and social inattentiveness. CORRECT: Flat affect and social inattentiveness, or spaciness, are examples of negative symptoms characteristic of schizophrenia. D) Delusional statements. INCORRECT: Delusional statements are not a negative symptom of schizophrenia. 6. Which nursing problem has priority? A) Ineffective community coping. INCORRECT: Ineffective community coping would be a nursing problem prior to admission, but it is not a priority problem for the nursing care plan after admission. B) Disturbed thought processes. CORRECT: Disturbed thought processes is a priority problem because Bob is delusional. C) Sensory-perceptual disturbance. INCORRECT: Bob has not demonstrated verbal or nonverbal cues of hallucinations or sensory-perceptual disturbance, so this is not a current nursing problem. D) Ineffective denial. INCORRECT: Ineffective denial is a conscious or unconscious attempt to reduce anxiety or fear which can impact health. There is not evidence that this is a current nursing problem. Medications 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. CORRECT: 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. B) Difficulty sleeping at night. INCORRECT: The side effects of Prolixin may lead to feelings of drowsiness, but this is not the reason for prescribing Prolixin. Sedative-hypnotics will be prescribed for sleep. C) Feelings of depression. INCORRECT: Prolixin is an antipsychotic with therapeutic effects for depression. D) Stabilize client's mood. INCORRECT: Prolixin is an antipsychotic and medications such as Lithium, carbamazepine (Tegretol), or valproic acid (Depakote) are mood stabilizers. 8. The nurse understands that a client with schizophrenia will experience which benefit from fluphenazine decanoate (Prolixin) if it is administered intramuscularly? A) Prevent more extrapyramidal side effects. INCORRECT: Prolixin can cause extrapyramidal side effects regardless of whether its given by injection or orally. B) Maintain long-term medication compliance. CORRECT: Prolixin is a long acting medication that is administered as an injection every 7-28 days to promote compliance with the medication regimen. C) Minimize side effects from benztropine (Cogentin). INCORRECT: Prolixin will not minimize side effects from benztropine (Cogentin). Cogentin is an antiparkinsonian agent used to relieve drug-induced extrapyramidal symptoms. D) Prevent risk of cardiac or renal disease. INCORRECT: Prolixin is contraindicated in clients with liver, renal, or cardiac insufficiency. 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? A) Beliefs about FBI surveillance. INCORRECT: Delusional thoughts alone do not justify the need for hospitalization. B) Diagnosis of schizophrenia. INCORRECT: A diagnosis of schizophrenia does not justify the need for involuntary hospitalization. C) Violence towards father. CORRECT: Risk for violence towards self or others are criteria for involuntary hospitalization. D) Guarded and suspicious. INCORRECT: 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)?

A) Mental status of client. INCORRECT: The mental status of the client is important documentation for an AMA request and dismissal, but another assessment is more important. B) Reason that client wants to leave. INCORRECT: The client's own description of why he wants to leave is important documentation for an AMA request, but another assessment is more important. C) Response to medications. INCORRECT: Response to medications is important to consider as it relates to the client's mental status, but it is not the most important consideration for releasing the client AMA. D) Potential danger to self or others. CORRECT: Potential for harm to self and others is the most important assessment in deciding to release the client AMA. Adverse Effects 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. 11. Which nursing action is best? A) Obtain a prescription to begin the Cogentin. CORRECT: 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. B) Monitor Bob for medication side effects. INCORRECT: The nurse can monitor the client for medication side effects, but this is not the priority nursing intervention. C) Ask Bob if he had any side effects from the Prolixin. INCORRECT: The nurse can ask the client if he had any side effects from the Prolixin, but if he was taking Cogentin, extrapyramidal effects may not have been evident. D) Do not give the Prolixin, and document the reason. INCORRECT: The nurse should continue giving Prolixin because "altered thoughts" is the priority nursing problem. 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. B) High anticholinergic effects and low extrapyramidal effects. INCORRECT: As compared with atypical antipsychotics, traditional antipsychotics do not have high anticholinergic effects and low extrapyramidal effects. C) Risk for agranulocytosis, fever, and elevated blood pressure. INCORRECT: Risk for agranulocytosis, fever, and elevated blood pressure occurs with Clozaril, an atypical antipsychotic. D) Blood dyscrasias such as thrombocytopenia. INCORRECT: Blood dyscrasias will be less likely observed with the traditional antipsychotics. 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? A) Akathisia. INCORRECT: Akathisia is motor restlessness, an extrapyramidal symptom. B) Dystonia. CORRECT: 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. C) Parkinsonism. INCORRECT: Symptoms of parkinsonism include fine tremors, cogwheel rigidity, and shuffling gait. D) Synergistic. INCORRECT: Synergistic reactions occur between two medications. 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? A) "Everything is confidential, so I doubt this will happen." INCORRECT: Explaining that it is doubtful that this will happen may lead the client to become defensive and angry, unless the nurse has established rapport with the client and attempted other strategies to intervene. B) "I know that this is probably unlikely. What do you think?" INCORRECT: Explaining that this is unlikely may result in the client feeling rejected and becoming angry. C) "What if the limousine does not get here?" INCORRECT: If the client perceives that the nurse is going along with the delusion, he may become confused, especially if the client senses that the nurse is trying to gain his cooperation. D) "It sounds like you are anxious to leave here." CORRECT: 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? A) Psychotic thinking. INCORRECT: The client demonstrates symptoms of psychosis, but this is not the best way to document the symptom. B) Delusional thoughts. CORRECT: The clients thoughts are delusional because he has false beliefs about being a movie star, and believes that a limousine will pick him up. C) Flight of ideas. INCORRECT: A flight of ideas is evident when a client has rapid, overproductive speech, and rapidly shifts from one topic to another with fragmented ideas. D) Confabulation. INCORRECT: Confabulation occurs when a client fills in memory gaps. 16. In planning this client's care, what is the most important short-term client outcome?

A) Interact without expressing delusional thoughts. CORRECT: 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. B) Create a support network within the community. INCORRECT: While the creation/identification of a network of support is important, especially as the client is preparing to be discharged, it is not the most important short-term client outcome. C) Identify at least one symptom management technique. INCORRECT: Teaching clients to manage symptoms and identify symptom management techniques is an important intervention for schizophrenia, but it is not the most important short-term client outcome. D) Identify actions to take to prevent relapse. INCORRECT: Identifying an action plan to prevent relapse is important, but other short-term outcomes are more important. 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? A) "What are you thinking right now?" INCORRECT: The client's nonverbal cues suggest that other interventions are more important. B) "Tell me about how you're feeling." INCORRECT: Inquiring about feelings is a useful communication strategy; however, another intervention is more useful based on the client's behaviors. C) "Have you been hearing any voices?" CORRECT: 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. D) "I notice that you talk to yourself." INCORRECT: Pointing out observations to the client is a useful communication strategy, but it is not the best nursing intervention. Bob smiles at the nurse, but refuses to answer. Group Therapy 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. CORRECT: 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. B) Unstructured group about personal issues. INCORRECT: A group about personal issues will be less structured, so the client may have poor attention and difficulty staying focused on a single task or accurately testing reality. C) Psychoeducational group about self-esteem. INCORRECT: Psychoeducational groups are beneficial, but selfesteem is more abstract and less concrete so the client may have difficulty focusing attention. A self-esteem group will not be the most therapeutic at this point in treatment. D) Supportive therapy group. INCORRECT: Supportive therapy will not be the most therapeutic group at this time.

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? A) Ineffective denial. INCORRECT: Ineffective denial is a conscious or unconscious attempt to reduce anxiety or fear which can impact health, and there is insufficient evidence based on the client's statement. B) Knowledge deficit. INCORRECT: Knowledge deficit occurs when the client lacks sufficient information about a problem or health need. The nurse can infer that knowledge deficit may be present, but another nursing problem is evident. C) Ineffective coping. INCORRECT: The client's statement does not suggest that he is coping ineffectively. D) Risk for adherence. CORRECT: 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? A) There is an imbalance of brain neurotransmitters, dopamine and serotonin. INCORRECT: It is accurate that serotonin has a modulating effect on dopamine, and both neurotransmitters have been implicated in schizophrenia, but this is not the best answer. B) There is a marked increase in brain volume which causes abnormal functioning. INCORRECT: Images of the brains of individuals with schizophrenia show decreased brain volume and abnormal functioning. C) Schizophrenia develops when at least one parent or distant relative has schizophrenia. INCORRECT: There is a genetic predisposition for schizophrenia; however, this is not the best answer. 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? A) Symptom triggers are stressors that lead to increased difficulty handling anger. INCORRECT: Difficulty handling anger may result from the inability to handle stressors or triggers, but this is not the best explanation of symptom triggers. 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.

C) Symptom triggers are behaviors that lead to medication noncompliance. INCORRECT: Triggers may lead to medication noncompliance, but this may not always happen if the client learns to cope with them. Consequently, this is not the best explanation of symptom triggers. D) Symptom triggers are stressors caused by hospitalization. INCORRECT: While symptom triggers may lead to hospitalization, this is not the best explanation of symptom triggers. 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. B) "Identifying symptom triggers can prevent the risk of violence and promote safety." INCORRECT: Identifying triggers can prevent the risk of violence, but triggers do not necessarily cause violence, so this is not the best answer. C) "It promotes communication with your case worker." INCORRECT: If a client talks to their case worker about difficulty with symptom management, it can promote interaction about the client's illness, but this is not the best explanation. D) "It allows you to increase your medications immediately." INCORRECT: Symptom triggers can be managed in a variety of ways including medications, coping skills, resources in the community, and other community support options, so this is not the best explanation. 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? A) Apathy. INCORRECT: Apathy is the lack of feelings, emotions, interests, or concerns. B) Anhedonia. INCORRECT: Anhedonia is the inability, or decreased ability, to experience pleasure, joy, intimacy, and closeness. C) Avolition. CORRECT: Avolition is a lack of energy or drive. D) Affective. INCORRECT: Affective refers to emotion and behaviors, such as hand and body movements, facial expression, and pitch of voice that can be observed when a person is expressing and experiencing feelings and emotions. 24. Which nursing problem should be included on the treatment plan? A) Impaired adjustment. INCORRECT: Impaired adjustment is the inability to adjust to situations that arise in the client's environment. B) Social isolation. CORRECT: Social isolation is manifested by behaviors such as the client sitting alone continuously without interacting with others.

C) Anxiety. INCORRECT: Anxiety is a subjective experience that is evidenced by the client's verbal and nonverbal actions. D) Confusion. INCORRECT: The client is sitting alone without peer interaction and does not exhibit confusion. Atypical Antipsychotics 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. 25. Which data is most important to obtain before Bob begins the Zyprexa, which is an atypical antipsychotic? A) Baseline weight. CORRECT: Weight gain occurs with the atypical antipsychotics, especially Zyprexa (olanzapine) and clozapine (Clozaril). B) Orthostatic blood pressure. INCORRECT: The client may experience dizziness as a result of orthostatic blood pressure changes, but this is not the most important nursing intervention. Orthostatic blood pressures are taken when the client reports dizziness. C) Complete blood count. INCORRECT: A complete blood count is not necessary if the client begins an atypical antipsychotic medication. Other lab work such as a fasting glucose level may be ordered because hyperglycemia can occur. D) Screening for tardive dyskinesia. INCORRECT: Screening for tardive dyskinesia should be done after 90 days exposure to an antipsychotic and every 6 months thereafter. However, this is not the most important intervention as the client changes medication. The nurse recalls that the atypical antipsychotics have different side effects than traditional antipsychotics. 26. Which side effects are characteristic of atypical antipsychotics? A) Increased tardive dyskinesia. INCORRECT: The incidence of tardive dyskinesia is less with atypical antipsychotics. B) Less incidence of weight gain. INCORRECT: Weight gain does occur with the use of atypical antipsychotics. C) Fewer extrapyramidal effects. CORRECT: Atypical antipsychotics have less extrapyramidal effects. D) More extrapyramidal effects. INCORRECT: Traditional antipsychotics have more extrapyramidal effects. 27. The nurse understands that an atypical antipsychotic like olanzapine (Zyprexa) requires what period of time to reach a steady state? A) 2 weeks. INCORRECT: Steady state is achieved in a different timeframe. B) 4 or more weeks. INCORRECT: Steady state is achieved in a different timeframe. C) 1 week. CORRECT: Steady state is generally reached in 1 week. D) 2 days. INCORRECT: Steady state is achieved in a different timeframe.

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). CORRECT: When a client has failed to respond to antipsychotic medications or longacting 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. B) Haloperidol decanoate (Haldol decanoate). INCORRECT: Haldol decanoate is not a medication with potentially life threatening side effects. C) Fluphenazine decanoate (Prolixin decanoate). INCORRECT: Prolixin decanoate is not a medication with potentially life-threatening side effects. D) Perfenazine (Trilafon). INCORRECT: Trilafon is not a medication with potentially life-threatening side effects. 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? A) Loose associations. INCORRECT: Loose associations refers to a lack of a logical relationship between thoughts and ideas so that speech is vague and unfocused. B) Tangential. INCORRECT: Tangential is the inability to return to the central point of the conversation so that the client never answers the original question. C) Monotone. INCORRECT: Monotone speech does not have any inflection in the tone of voice. D) Poverty of speech. CORRECT: 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? A) Concrete thinking. INCORRECT: Concrete thinking is the inability to abstract so that clients interpret the literal meaning of words. B) Flight of ideas. INCORRECT: Flight of ideas is rapid shifting from one topic to another and fragmented ideas. C) Word salad. INCORRECT: Word salad is a series of words that seem totally unrelated. D) Thought blocking. CORRECT: 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 Bobs 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? A) Observe Bob for signs of talking to himself. INCORRECT: A client who talks to self may be experiencing auditory hallucinations. B) Talk to Bob for at least 20 minutes. CORRECT: The nurse should be able to talk to the client without observing the presence of delusional thoughts. C) Ask Bob to describe how he feels. INCORRECT: Asking the client how he feels will not determine if the client is still delusional. D) Ask Bob to explain how the medication helps him. INCORRECT: Talking to the client about medications will not assess whether or not the long-term goal is met. 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? A) "Do you have a history of violence?" INCORRECT: A history of violence is the best predictor of violence, but it will not determine if the client is currently a risk for harm to self or others. B) "Tell me about the relationship with your father." INCORRECT: Interaction about the relationship with the father may not assess the risk for harm. C) "How do you feel about your father now?" INCORRECT: This statement may be helpful, but it does not directly assess the risk for harm. D) "Do you think about hurting anyone now?" CORRECT: 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. CORRECT: 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. B) Review education about medications. INCORRECT: Medication education is important, but this is not the most important activity.

C) Practice social skills. INCORRECT: Social skills are important for clients with schizophrenia, but this is not the most important group activity. D) Identify community coping resources. INCORRECT: Providing resources for coping should be included in the discharge plan, but this is not the most important group activity. 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? A) Talk about specific support systems. INCORRECT: This is a step of effective symptom management techniques, but not the first. B) Review current ways to manage symptoms. INCORRECT: This is a step of effective symptom management techniques, but is not the first. C) Identify problem symptoms. CORRECT: Identifying problem symptoms is the first step of effective symptom management. D) Discuss other ways to manage symptoms. INCORRECT: This is a step of effective symptom management techniques, but is not the first. 35. After implementing the first step, what step is taken next? A) Identify current ways to manage symptoms. CORRECT: 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. B) Talk about specific support systems. INCORRECT: This is the third step of effective symptom management techniques. C) Discuss other ways to manage symptoms. INCORRECT: This is the fourth step of effective symptom management techniques. D) Develop a new symptom management plan. INCORRECT: This is the final step of effective symptom management techniques. 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. CORRECT: 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. B) Smoke more cigarettes. INCORRECT: Increased caffeine and nicotine can affect the action of psychotropic medications and increase the metabolism of the medications. C) Decrease caffeine use. INCORRECT: Decreasing caffeine consumption will make a difference with the metabolism of psychotropic medications, but this is not the best strategy if the client is hearing voices.

D) Take more medication. INCORRECT: Taking additional medications increases adverse effects and other problems, and is not the most desirable intervention. Relapse Prevention The nurse plans to talk about relapse prevention. 37. What is the most common cause of relapse in the client with schizophrenia? A) Symptom management. INCORRECT: Symptom management is important to prevent relapse rather than cause relapse. B) Medications. CORRECT: 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. C) Lack of community support. INCORRECT: A lack of support can lead to relapse, however, this is not the most common cause. D) Health practices. INCORRECT: Poor health practices can relate to relapse, but this is not the most common cause. 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. B) "Maybe you forgot to take some of your medication." INCORRECT: A client may forget to take some medications, but this does not necessarily lead to hospitalization. C) "How long have you been taking your medications?" INCORRECT: The nurse can question the client about his medications, but this is not the best response. D) "Compliance with medications will prevent relapse." INCORRECT: Compliance with medications can help prevent relapse, but relapse can still occur. 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. CORRECT: The greatest benefit of the case worker is to coordinate services related to housing, finances, and medical appointments, for example. B) Make sure Bob takes his medications. INCORRECT: The case worker can work to ensure that the client is taking medications as prescribed, but there is another more important role. C) Empower Bob to be independent. INCORRECT: The case worker can empower the client and be an important client advocate, but there is another more important role.

D) Provide guidance for disability income. INCORRECT: The case worker will often assist the client with financial issues, as needed, but the case worker has another more comprehensive role. Case Outcome 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.