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1. Which medication is most likely to be prescribed for an outpatient with a diagnosis of chronic undifferentiated schizophrenia and a history of medication noncompliance?
a) chlorpromazine (thorazine)
b) imipramine (tofranil)
c) lithium carbonate (lithane)
d) fluphenazine decanoate (prolixin decanoate)
2. A patient's medication order reads: "Thioridazine (mellaril) 200 mg orally four times a day and 100 mg orally as needed." Based on this order, the nurse should:
a) administer the medication as prescribed
b) question the physician about the order
c) administer the order for 200 mg orally four times a day but not for 100 mg orally as needed
d) administer the medication as prescribed but closely observe the patient for adverse effects
3. The extrapyramidal effects associated with antipsychotic agents can be controlled by which medication?
a) perphenazine (trilafon)
b) doxepin ( sinequan)
c) amantadine (symmetrel)
d) clorazepate dipotassium (tranxene)
4. Which non-antopsychotic medication is used to treat some patients with schizophrenia disorder?
a) phenelzine sulfate (nardil)
b) chlordiazepoxide (librium)
c) lithium carbonate
d) imipramine
Situation: T.S., a19 year old sophomore, walks into the college health center and asks to speak with a counselor or therapist. For the past month, she has been having difficulty concentrating, and her grades have declined because of this. She finds herself daydreaming, lost in her own thoughts, and feeling out of it both in class and out.
5. The nurse prepares to conduct the patient interview and initial evaluation. How should she begin?
a) hello, T., I'm R.N., a nurse here at the health center. I need to learn more about you and your reasons for coming in. Then we'll discuss how the health center can help you
b) Hi, T. My name is R. Why don't we sit and chat for awhile. How can I help you?
c) Ms. S., I'm the nurse assigned to interview you. If necessary, the psychiatrist also will evaluate you today. Otherwise, you'll see him another time
d) Ms. S., I'm Mrs. N., a nurse. You mentioned that you feel out of it. Can you tell me more about this?
6. T. begins to tell the nurse about herself. Which statement indicates possible difficulties in relating to others?
a) I miss my parents and friends at home very much and feel homesick
b) I have only two close friends at college and consider myself a shy person
c) my roommate at college is all right, but I don't consider her a shy person
d) I consider myself a loner and prefer reading and studying to going out and socializing
7. In recounting her family history, T. suddenly begins crying and says. "My mother was schizophrenic. She was in and out of the hospital for years. That's not what's wrong with me, is it?" The nurse should respond by saying:
a) what makes you think you're schizophrenic like your mother?
b) it's really too soon to tell, but heredity may play a role in schizophrenia
c) schizophrenia is a chronic illness, and since this is the first time you're having a problem, I doubt if you're schizophrenic
d) I'm not yet sure what your problem is
8. When T. returns to the health center 1 week later, she tells the nurse that she is not sure whether anything can be done to help her. How should the nurse respond?
a) you certainly are down in the dumps. You must have had a lousy week
b) I wish you would give us a chance. We really do have an excellent staff here
c) let's talk about the reasons you seem to be feeling so hopeless right now
d) that is a very self-defeating attitude. You can't be helped unless you want to be
9. T. tells the nurse that she feels she cannot handle her schoolwork. Her grades have gone from A's and B's to C's, and she even may be failing a course. T. asks the nurse if she should withdraw from all her classes. Which response is most helpful?
a) do you really think withdrawing from all your classes would be best right now?
b) we can discuss the choices you have and the pros and cons of each
c) I think you should discuss this with your professors before making such a decision
d) if you are feeling so overwhelmed by the demands of your classes, that might be the best thing to do
10. During one of her sessions with the nurse, T. mentions that her roommate borrowed her favorite dress without asking and then ruined it by spilling grease on it. She describes this episode in a matter-of-fact way and denies feeling angry about the incident. Then she adds, "I rarely get angry at anyone." To explore the patient's feelings, the nurse should say:
a) you are very nice person to feel angry about having your best dress ruined like that
b) I can't believe you aren't angry or at least annoyed by your roommate behavior. Why don't you level with me
c) I think I'd be angry about something like that. What were your thoughts when you first found out about it?
d) You know anger is a normal response to events like that. tell me how you really feel about what she did
11. T. eventually is able to admit that she was somewhat annoyed by her roommate's actions and recognizes that she feels uncomfortable getting angry even when she probably should. Which initial patient goal is most appropriate?
a) the patient will express her anger to her roommate regarding the ruined dress
b) the patient will be able to ask her roommate to replace the damaged dress
c) the patient will begin to identify and discuss with the nurse events that arouse her feelings of anger
d) the patient will demonstrate that she has learned to repress her angry feelings
12. T. continues her weekly sessions at the health center. She does not exhibit any psychotic symptoms, and her primary difficulties involve establishing and maintaining relationships with others and denying her anger. A medical diagnosis of personality disorder is considered. Based on the above symptoms and her knowledge of the disorder, the nurse would suspect the patient to have which type of personality disorder?
a) schizoid
b) schizotypal
c) borderline
d) antisocial
ANSWERS AND RATIONALE
1) D
- fluphenazine decanoate (prolixin decanoate) is a long-acting ant-psychotic agent given by injection. Because it has a 4-week duration of action, fluphenazine is commonly prescribed for outpatients with a history of medication noncompliance. The antipsychotic agent chlorpromazine (thorazine) must be administered daily to maintain adequate plasma levels, which necessitates compliance with the dosage schedule. Imipramine (tofranil), a tricyclic antidepressant, and lithium carbonate (lithane), a mood stabilizer, are generally not used to treat patients with chronic schizophrenia.
2) B
- the nurse must question this order immediately. Thioridazine (mellaril) has an absolute dosage ceiling of 800 mg/day. Any dosage above this level places the patient at high risk for toxic pigmentary retinopathy, which cannot be reversed. The order, as written, allows for administering more than the maximum 800 mg/day; it should be corrected immediately, before the patient's health is jeopardized.
3) C
- Amantadine (symmetrel) is an anticholinergic drug used to relieve drug-induced extrapyramidal adverse effects, such as muscle weakness, involuntary muscle movement, pseudoparkisonism, and tardive dyskinesia. Other anticholinergic agents used for extrapyramidal reactions include benzotropine mesylate (cogentin), trihexyphenidyl (artane), biperiden (akineton), and diphenhydramine (benadryl). Perphenazine is an antipsychotic; doxepin, an antidepressant; and chlorazepate, an antianxiety agent. Because these medications have no anticholinergic or neurotransmitter effects, they do not alleviate extrapyramidal reactions.
4) C
- lithium carbonate, an antimania drug, is used to treat patients with cyclical schizoaffective (a psychotic disorder once classified under schizophrenia that produce affective symptoms, including maniclike activity). Lithium helps control the affective component of this disorder. Phenelzine sulfate (Nardil) is a monoamine oxidase inhibitor prescribed for patients who have not responded to other antidepressant drugs, such as imipramine. Chlordiazepoxide (librium), an antianxiety agent, is generally contraindicated in psychotic patients. imipramine, primarily classified as an antidepressant agent, also is used to treat patients with agoraphobia and those undergoing cocaine detoxification.
5) A
- each interview should begin with a clear statement of introduction that defines the purpose of the interview. Because the patient has come to the health center for the first time, informality, use of first names only, and an inviting to sit and chat are inappropriate. Also inappropriate are introductions with last names only, using clinical terminology, and abruptly mentioning the psychiatrist; this type of introduction is cold and distancing. Only after the nurse has introduced herself, defined her role, and told the patient what to expect from the interview should she begin exploring the patient's problem.
6) D
- the patient's self-description as a loner who prefers solitary activities, such as reading and studying, over socializing clearly suggests that she may be having difficulty relating to others. Shy persons who have established and maintained relationships may desire additional social skills but usually can relate meaningfully to others. Feeling homesick and missing family and friends is not unusual or abnormal; neither is not liking everyone.
7) A
- the nurse should explore the basis for T.'s fear that she may be schizophrenic because her response can provide clues to her current difficulties and self-concept. Once the nurse understands the patient's thoughts and feelings, she can better respond to her question. Although it is true that a diagnosis cannot yet be made and that heredity may be a factor in schizophrenia, giving the patient this information would probably not be helpful and does not encourage the patient to express concerns. Although schizophrenia is a chronic illness, the patient is in a vulnerable age-group (ages 15 to 35) for the onset of the disease. The nurse should not consider the patient schizophrenic until more data are obtained and the physician makes a positive diagnosis.
8) C
- by reflecting T.'s apparent hopelessness and inviting her to discuss her feelings, the nurse provides an opportunity for the patient to explore her perception of the situation. Acknowledging that T. is down in the dumps and attributing this to lousy week tells rather than asks the patient how she feels. Lecturing T. about how good the staff are or how her negative attitude will impede her progress denies her feelings and is judgmental and nontherapeutic.
9) B
- the nurse's role is to assist the patient in exploring and evaluating alternatives -- not to tell the patient what she thinks is best. Encouraging her to discuss the alternatives and helping her evaluate them promotes the patient's growth. Judgmental responses, such as "Do you really think..." or "I think you should..." belittle the patient by implying that the nurse knows best. These responses also fail to encourage the patient to explore all the possible choices. The nurse should not agree with the patient's decision until the situation has been discussed and understood.
10) C
- using self-disclosure in response to T.'s situation shows that the nurse emphatizes with the patient and relays that the negative feelings are acceptable. By encouraging the patient to discuss her thoughts, the nurse seeks to release T.'s underlying feelings. Promoting T.'s denial of anger by telling her that she must be a nice person is not helpful. Confrontational approaches, such as "Level with me" and "Tell me how you really feel," would put T. on the defensive and inhibit her expression of feelings.
11) C
- T. needs to learn that it is acceptable to express her anger before she learns to talk about her feelings. The nurse is a safe, supportive person with whom T. can begin this process. Once the patient can admit her feelings to herself, she can begin expressing them more directly to others. Repression (barring of unacceptable thoughts or painful experiences from consciousness) is not a desirable goal because the patient would expend much energy containing such thoughts and have difficulty focusing on day-to-day issues.
12) A
- Schizoid personality disorder is characterized by difficulty in forming social relationships and in expressing anger, preference for solitary activities, emotional detachment, daydreaming, and indecisiveness. Schizotypal personality is manifested by oddities of thinking, perception, speech, and behavior that are not severe enough to be labeled schizophrenia. Borderline personality marked by instability in several areas of development, is evidenced by unstable mood, poor relationships, impulsivity, and self-destructive behavior. The diagnosis of antisocial personality disorder is applied only to patients older than age 18 who have a history of conduct disorder before age 18. Conduct disorders are characterized by behaviors such as truancy, lying, problems in school, and running away.
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