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Situation: L., a 28 year old woman, has been hospitalized for most of the past 12 years. For the past 2 1/2 years, she has been on a unit for chronically mentally ill patients. Her psychiatric diagnosis is disorganized type schizophrenia. Her behavior is labile, fluctuating from childishness to incoherence to loud yelling to making growling noises to demonstrating slow but appropriate interaction. L., needs assistance with all her activities of daily living (ADLs). In the morning, she remains in her nightgown unless helped to dress
24. Which behavior is characteristic of a patient with disorganized type of schizophrenia?
a) extreme social impairment
b) suspicious delusions
c) waxy flexibility
d) appropriate affect
25. L. continues to be unable to complte her ADLs without staff direction ans assistance. The nurse formulates a nursing diagnosis of Dressing and grooming self-care deficit related to inability to function without assistance. An appropriate patient goal is that within 1 month, L. will be able to:
a) complete ADLs independently
b) complte ADLs with only verbal encouragement
c) complete ADLs with assistance in organizing her grooming items and clothing
d) complete ADLs with complete assistance
26. L. is seen sitting in the day room looking disheveled. Her slacks are stained and her blouse is incorrectly buttoned so that one side hangs several inches below the other. The nurse can help L. most by:
a) telling her that her slacks are soiled and her blouse needs to be rebuttoned
b) taking her to her room, selecting another pair of slacks, and fixing her blouse
c) reminding her that she should complete her ADLs before going to the dayroom
d) bringing her to a mirror and helping her identify what needs to be corrected
Situation: M., a 24 year old college student, is brought to the hospital by her boyfriend with whom she has been living for the past 6 months. He reports that M.'s behavior has become very strange over the past week. She has become more and more withdrawn to the point that yesterday she sat on a chair in her room with her eyes closed, not moving for 6 hours, until he carried her to bed. He says that at first he thought she was just depressed about the recent death of a friend, but now he thinks she's "flipped out." M. is admitted with a diagnosis of catatonic schizophrenia.
27. During the physical assessment, M.'s arm remains outstretched after her pulse and blood pressure are taken, and the nurse must reposition it for her. The patient is manifesting:
a) suggestibility
b) negativity
c) waxy flexibility
d) retardation
28. M. keeps her eyes closed and does not respond to questions from the nurse or the physician. The nurse keep in mind that:
a) the patient is aware of what is going on around her and could respond if she wanted
b) the patient may be able to hear what is happening around her even though she does not respond
c) the patient cannot hear or comprehend what is being said to her
d) the patient is in a regressed state and should be treated like a frightened child
29. M. remains in bed with her eyes closed. She continues to be unresponsive and does not eat or drink. The physician orders chlorpromazine (thorazine) 100 mg orally four times a day. Under these circumstances, the nurse should:
a) withhold the medication until the patient becomes more responsive and eats
b) administer the appropriate dose of chlorpromazine in a concentrate form
c) administer the chlorpromazine as needed
d) request an order for chlorpromazine to be administered intramuscularly
30. While M. remains is an unresponsive state, the nurse's highest priority is assess the patient's:
a) fluid intake and output
b) daily activity level
c) communication level
d) response to others
31. One evening, M. suddenly begins running up and down the hall. She strips off her clothing and strikes out wildly at anyone she passes. This incident of catatonic excitement is considered:
a) a response to increased activity on the unit
b) self-limiting episode that will subside as suddenly as it began
c) an occurrence related to internal not external stimuli
d) an indication of patient improvement
32. All of the following interventions would be appropriate for a patient experiencing catatonic excitement except:
a) clearing the area of other patients
b) calling for assistance of at least three other staff members
c) obtaining an order for and preparing an as-needed dose of chlorpromazine
d) restraining the patient and calling for help
ANSWERS AND RATIONALE
24) A
- Rationale: Disorganized type schizophrenia (formerly hebephrenia) is characterized by extreme social impairment, marked inappropriate affect, silliness, grimacing, posturing, and fragmented delusions and hallucinations. A patient with a paranoid disorder typically exhibits suspicious delusions (belefs that evil forces are after him). Waxy flexibility, a condition in which the patient's limbs remain fixed in uncomfortable positions for long periods, is characterized of catatonic schizophrenia.
25) C
- Rationale: L.'s history of hospitalization and her disorganized personality caused by schizophrenia have affected her ability to care for herself. Interventions should be directed at helping her complete her activities of daily living (ADLs) with the assistance of staff members, who can provide needed structure by helping her select her grooming items and clothing. This goal promotes realistic independence. As L. improves and attains the established goal, new goals can be set that are directed at the patien's completing. ADLs with only verbal encouragement and, ultimately, completing them independently. L.'s condition does not indicate a need for complete assistance, which would only foster dependence.
26) D
- Rationale: the nurse should help L. to recognize for herself what needs to be corrected. Taking her to a mirror encourages reality testing (determining objective reality) and helps develop self-perception with the nurse's support and guidance. Providing L. with an opportunity to attend to her appearance promotes mastery of ADL skills and is more therapeutic than telling her what is wrong or fixing her clothes for her.
27) C
- Rationale: Waxy flexibility - an ability to assume and maintain awkward or uncomfortable positions for long periods - is characteristic of catatonic schizophrenia. Patients often remain in these awkward positions until repositioned by someone else. Patients with dependency problems may demonstrate suggestibility, a response pattern in which the patient easily agrees to the ideas and suggestions of others rather than making his own independent judgments. Negativity (resistance, for example, to being moved or being asked to cooperate) and retardation (slowed movement) are also seen in catatonic patients.
28) B
- Rationale: the nurse should assume that a withdrawn, unresponsive patient may be able to hear what is being said and what is going on around her. She should address the patient by name, tell her what is being done, and orient her to person, place, and time. All staff members should be respectful of the patient's condition and careful when conversing in the patient's presence. The patient's withdrawal is an extreme defense mechanism that is not consciously controlled and therefore is not willful. Consistent and caring interventions can help the patient develop trust and eventually reduce the need for such extreme behavior. Although the patient may experience extreme and fear, treating her like a child is inappropriate and reinforces dependency.
29) D
- Rationale: because the physician has ordered chlorpromazine (Thorazine) to be administered orally and the patient is not eating or drinking, the nurse should request an order for IM administration instead. Giving oral forms of medication (including tablets and concentrates) while the patient is in this state would be unsafe and would not ensure that the proper dose is being received. After administering the IM dose,the nurse should closely monitor the patient's vital signs; postural hypotension is a possible side effect. The patient requires adequate doses of chlorpromazine, an antipsychotic, to relieve her symptoms; giving this drug on an as-needed basis would not ensure the proper dosage necessary for a therapeutic effect.
30) A
- Rationale: the nurse should monitor M.'s fluid intake and output closely. The patient's refusal to eat or drink and her limited mobility put her at high risk for severe fluid and electrolyte imbalance, dehydration, inadequate nutrition, constipation, and urine retention. Vital signs and skin assessment can also indicate fluid volume deficit. Assessing the patient's activity level, communication level, and response to others is of secondary importance.
31) C
- Rationale: Catatonic excitement, which is characterized by extreme purposeless motor activity, agitation, and striking out wildly, appears related to internal rather than external stimuli. It differs from manic excitement, which is escalated by environmental stimuli (and therefore is somewhat more predictable) and can be lessened by a quiet setting. Catatonic excitement is not self-limiting; it may not stop without intervention. A patient experiencing catatonic excitement needs immediate attention to protect herself and others from injury; it does not indicate improvement.
32) D
- Rationale: a patient experiencing catatonic excitement is extremely agitated and potentially dangerous to herself and others. The nurse should not attempt to restrain the patient without adequate assistance. At least three staff members should approach the patient and have a plan for restraint, if needed. While waiting for staff backup, the area should be cleared of other patients as well as chairs or objects that could be thrown or pose a safety hazard. The nurse should prepare an as-needed injection of chlorpromazine, if ordered, so that the patient ca be medicated once safely restrained.
Related Topics:
- Online Nursing Practice Test about Psychotic Disorders (33-43)
- Go back to Online Nursing Practice Test about Psychotic Disorders (1-12) to start the test from the beginning.
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