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NR202 Test 3 Schizophrenia


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Diagnostic criteria: two or more characteristic symptoms has to be present for a significant portion of time during a one month period and persisting for at least six months
-Disorganized Speech
-Grossly disorganized behavior
-Catatonic behavior
-Negative symptoms.
Diagnostic criteria areas other than symptoms
-One or more areas of social or occupational functioning markedly below previously achieved level: Work, Interpersonal relations, Self-care

-No presence or insignificant duration of major depressive, manic, or mixed episodes occuring concurrently with active symptoms
-Not a direct physiologic effect of substance or medical condition
Schizophrenia subtypes
Paranoid type
Disorganized type
catatonic type
Undifferentiated type
Residual type
What category is the Drug clozapine in
Clozapine is excellent drug because
Atypical (Novel)

little or no EPS side effects
Prodromal phase
A transitional preschizophrenic phase that occurs a month to year(s) before the first psychotic break
-withdrawal, difficulty relating to others
-Impairment of role functioning
-inability to concentrate
-Intrusive thinking and preoccupations
-Neglect of self-care
-Feeling that something is strange or wrong
-Misinterprets or gives symbolic meanings to ordinary events.
Schizophrenia: explain positive and negative symptoms
Positive symptoms are excessive characteristics
Negative symptoms are an absence of normal characteristics
Explain paranoid type schizophrenia
-Preoccupation with delusions or auditory hallucinations
-Lacks organized speech, disorganized or catatonic behavior, or flat or inappropriate affect.
Explain disorganized type
Disorganized speech, disorganized behavior, and flat or inappropriate affect.
Explain catatonic type
At least two or more of the following present:
-Motor immobility or stupor
-Excessive purposeless motor activity
-Extreme negativism
-Posturing, stereotyped movements, prominent mannerisms, or prominent grimacing
Echolalia-repeating the speech of another person
Echopraxia-Repeating the movements of another person.
Explain undifferentiated type
Only characteristic symptoms present but does not meet criteria for other subtypes
Explain residual type
Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior
-Negative symptoms persist or two or more positive symptoms are present in attenuated forms such as odd beliefs or unusual perceptual experiences.
Acute Phase of (after prodromal phase, before residual phase of schizophrenia )
Positive symptoms-alterations in thinking
Delusions: List types and explain some
Delusions -false beliefs
Types of delusions:
-Persecutory-The false belief that one is being singled out for harm by others; this belief often takes the form of a plot by other people in power against the person.
Sam believed that the secret service was planning to kill him/poison his food/ etc

-Grandiose-The false belief that one is a very powerful and important person-Sally believed that she was Mary Magdalene and that Jesus controlled her thoughts and was telling her how to save the world

-Nihilistic or somatic-The false belief that the body is changing in an unusual way (rotting inside)-David told the doctor that his brain was rotting away.


-Thought broadcasting-The belief that one's thoughts can be heard by others "My brain is connected to the world mind. I can control all heads of state through my thoughts"

-Thought insertion-The belief that thoughts of others are being inserted into one's mind ("They make me think bad thoughts")

-thought control-Belief that one's body or mind is controlled by an outside agency. "There is a man from darkness who controls my thoughts and electrical waves."

-thought withdrawal-The belief that thoughts have been removed from one's mind by an outside agency ("The devil takes my thoughts away and leaves me empty.")
-Ideas of reference
Acute Phase of (after prodromal phase, before residual phase of schizophrenia )
Positive symptoms-alterations in thinking
Speech deficits-types and explain
Speech deficits: types
-Loose associations- Associations are threads that tie one thought to another and one concept to another. In schizophrenia, these threads are missing, the connections are interupted. Thinking becomes haphazard, illogical, and confused.
Nurse: are you going to the picnic today
Client: I'm not an elephant hunter, no tiger teeth for me.

-Clang association-Clang association is the meanigless rhyming of words, often in a forceful manner... (On the track...have a Big Mac...or get the sac...), in which the rhyiming is often more important than the context of the word

-Word salad-A jumble of words that is meaningless to the listener and perhaps to the speaker as well. "Frame woes oblivious waylaid cactus...mud and stars and thump-bump going"

-Neologisms-words a person makes up that have special meaning for the person. "I was going to tell him the mannerologies of his hospitality won't do."
Acute phase positive symptoms
Alterations in thinking
Name cognitive deficits
Concrete thinking
Acute phase positive symptoms (excessive symptoms) Alterations in thinking: Name
Hallucinations-False sensory perceptions


Loss of Ego boundaries
Acute phase positive symptoms (excessive symptoms)
Alterations in Behavior
Odd or bizarre behavior
-inappropriate to unusual social conventions
-Odd mannerisms or gestures
-Repetitive behavior
-Waxy flexibility
Acute phase-Negative symptoms (absence of normal characteristics)
Symptoms that interfere with adjustment and social functioning.
-Blunted affect
-Poverty of speech
-Thought blocking
-Social Isolation
Mood symptoms of Schizophrenia
Residual phase of schizophrenia
-Schizophrenia is characterized by periods of remission and exacerbation
-Residual phase usually follows acute phase
-Symptoms similar to the prodromal phase
-Flat affect
-Impairment of role funcitoning
-Residual impairment often increases between episodes of active psychosis
Assess associated risk factors
Suicide/Depression Risk factors
-Depressive symptoms
-More florid positive symptoms
-numerous relapses early in illness
Assess Associated Risk factors
Water intoxification
-Also called psychosis based polydipsia
-Occurs in 3%-6% of hospitalized patients
Ingests more than 10-15 L of fluid a day
When untreated leads to sodium depletion, cerebral edema, seizures, brainstem herniation, and death
-Constantly carries fluids, goes to fountain or restroom
-Thought to be medication induced
Assess Associated Risk Factors
Substance Abuse
Up to 50% of schizophrenic patients in the hospital have co-occuring substance abuse (at least 70-80% smoke)
Cannabis, alcohol and cocaine most frequently used
Use attributed to relieve depression, relax, and to counteract negative symptoms
Increases the risk for negative outcomes
-More and longer hospitalizations
-Lower treatment compliance
-Greater risk of suicide, violence, incarceration, HIV
Assess Associated Risk Factors
Violent Behavior
Threats of violence and aggressive outbursts may occur in the acute or relapse phases

General risk factors
-previous arrests
-Substance abuse
-Positive symptomology
Nursing Diagnosis for Schizophrenia
Risk for violence
Alteration of Thought Process
Sensory-perceptual alterations
Social Isolation
Self Care Deficit
Impaired Verbal Communication
Knowledge Deficit
Outcomes of treatment
Reduction of both positive and negative symptoms
Improved level of functioning
Improved quality of life
Increased knowledge and involvement of family of caregivers
Prevention of relapse
General Interventions: Always establish trust
-Ensure safe, nonstimulating environment
-Assess the nature and severity of the hallucinations and delusions
-Offer reassurance about safety of the environment and your willingness to help

-Use brief short-words and sentences
Do not use abstract terms and avoid humor
Use supportive statements that recognize how scary or confusing things seem
Frequent, brief interactions
Check at least every 15 minutes

-engage in activity
-Provide daily routine and structure
-Assist in meeting ADLs
Assess for stressors that increase symptoms
-Orient and eliminate sources of stress
-Ensure rest and sleep
-Reinforce expressions of reality based thinking
-Assess and treat:
-Medical conditions
-Substance abuse

Involve Family
Provide education in symptom management and relapse prevention.
Interventions: Hallucinations
-Assess for command hallucinations
-Determine ways in which individual has tried to cope
-Convey understanding of underlying feeling
-If client denies, but gives non-verbal indications, ask gently if the voices are telling him not to discuss them
Avoid using logic to convince the client he is wrong
Be alert for signs of increasing fear, anxiety and agitation
If asked, point out simply that you are not experiencing the same stimuli, convey understanding and distract-don't argue
Interventions: Delusions
Assess delusional content
Determine when delusional thinking is most prominent
Be aware that delusions are how the client is experiencing reality, don't argue or correct using facts
convey understanding of underlying feeling
try to distract client and refocus on the present reality/engage in activity
Specific interventions for paranoia
-Always keep your promises
-Explain what you are going to do before you do it
-Diffuse anger with non-defensiveness
-Do not do things that can be misinterpreted
-Provide noncompetitive activities.
Interventions for Movement disorders
-Use "prns" cautiously
-Assess for SE and use rating scales to assess for EPS (Simpson for Acute and AIMS for Tardive)
respond immediately to EPS symptoms
Monitor ongoing symptoms-using rating scales
Teach and support patient and family
Neuroleptic Malignant Syndrome
-Uncommon but potentially fatal
-May occur with just one dose

-Profuse sweating
-Rigidity of extremities
-Elevated temperature
-Elevated CPK
-Tremors, agitation,

Intervention: Stop all medication
-Reduce fever
-Replace fluids and electrolytes
-Consider use of dopamine agonists.
Antipsychotic Medications
Typical (traditional)
-Haloperidol (Hadol and hadol decoanate)
-Fluphenazine (Prolixin and prolixin decoanate)
-Trifluoraperazine (stelazine)
-Thiothixene (navane)
-Chlorpromazine (Thorazine)
-Thioridazine (Mellaril)
Antipsychotic Medications
-Clozapine (clozaril)
-Resperidone (Resperdal and risperdal consta (long acting injectable)
Olanzapine (Zyprexa) Quetiapine (seroquel), Ziprasadone (Geodon), Anpiprazole (Abilify)
Medications To Treat EPS
Benztropine (Cogentin)0.5-6mg

Procyclindine (Demadrin)5-20 mg
Trihexyphenidyl 1-15 mg

Diphenhydramine (benedryl) 10-400 mg

Dopaminergic agonists
Amantadine (Symmetrel)100-300 mg
Bromocriptine (Parlodel)2.5-100 mg
Minimizing other side effects
Dry mouth-give intervention
Frequent sips of water, sugarless candies or gum
Minimizing other side effects

Constipation-give intervention
Constipation: High fiber diet, increase fluids and exercise
Minimizing other side effects
Blurred vision & Photosensitivity -give intervention
Blurred vision
Avoid hazardous tasks, reassure the patient

Protective clothing, sunglasses, sun block
Minimizing other side effects
Urinary hesitation-give intervention
Urinary hesitation Increase fluid, monitoring of urine output, voiding whenever urge is present
Minimizing other side effects
Postural Hypotension-give intervention
Postural Hypotension Slow change of position (lying to standing), adequate hydration, monitoring of BP, use of elastic stockings if necessary
Minimizing other side effects
Weight gain-give intervention
Weight gain Increase exercise, monitor caloric intake, check for fluid retention, monitor for onset of diabetes
Reasons for noncompliance
Distressing or uncomfortable side effects, lack of awareness or denial of the illness, stigma, confusion about dosage or timing, feeling better, complexity of medication regime, treatment access problems, substance abuse
Improving Compliance
Develop and maintain a strong therapeutic relationship, assess for client self adjusting dosages, support and educate patient and family, treat emergent side effects immediately, try decoanate preparation. Reduce environmental barriers: cost, access
Psychoeducational Plan
Teach Client: signs and symptoms, course of illness, benefits of treatment (outcomes), medication actions and side effects, techniques to minimize side effects, stress management techniques, early signs of relapse
Methods to improve Patient Education
Simplify information, reduce distractions, provide visual as well as verbal info, use unambiguous terms and simplified language, teach small segments, reinforce often, do not crowd visual teaching tools, implement teaching as symptoms and medication dosages are stabilized.
1. Schizophrenia is best characterized as
A. split personality.
B. multiple personalities.
C. ambivalent personality.
D. deteriorating personality.
D. deteriorating personality.
The course of the disease is marked by recurrent acute exacerbations. With each relapse of psychosis, an increase in residual dysfunction and deterioration occurs.
2. A descriptor for a subtype of schizophrenia is
A. delusional.
B. dissociated.
C. disorganized.
D. developmental.
C. disorganized.
Disorganized schizophrenia is a subtype of schizophrenia listed in the DSM-IV-TR and refers to the most regressed and socially impaired of all the schizophrenic disorders.
3. Which of the following would be assessed as a negative symptom of schizophrenia?
A. Anhedonia
B. Hostility
C. Agitation
D. Hallucinations
A. Anhedonia
Negative symptoms include the crippling symptoms of affective blunting, anergia, anhedonia avolition, poverty of content of speech, poverty of speech, and thought blocking.
4. The type of altered perception most commonly experienced by clients with schizophrenia is
A. delusions.
B. illusions.
C. tactile hallucinations.
D. auditory hallucinations.
D. auditory hallucinations.

Hallucinations, especially auditory hallucinations, are the major example of alterations of perception in schizophrenia. They are experienced by as many as 90% of schizophrenic individuals.
5. What is the most common course of schizophrenia? Initial episode followed by
A. recurrent acute exacerbations and deterioration.
B. recurrent acute exacerbations.
C. continuous deterioration.
D. complete recovery.
A. recurrent acute exacerbations and deterioration.

Schizophrenia is usually a disorder marked by an initial episode followed by recurrent acute exacerbations. With each relapse of psychosis an increase in residual dysfunction and deterioration occurs.
6. The causation of schizophrenia is currently understood to be
A. a combination of inherited and nongenetic factors.
B. excessive amounts of the neurotransmitter dopamine.
C. excessive amounts of the neurotransmitter serotonin.
A. a combination of inherited and nongenetic factors.

Causation is a complicated matter. Schizophrenia most likely occurs as a result of a combination of inherited genetic factors and extreme nongenetic factors (such as virus, birth injuries, nutritional factors) that can affect the genes governing the brain or directly injure the brain.
7. Which symptom would not be assessed as a positive symptom of schizophrenia?
A. Delusion of persecution
B. Auditory hallucinations
C. Affective flattening
D. Idea of reference
C. Affective flattening

Positive symptoms are the attention-getting symptoms such as hallucinations, delusions, bizarre behavior, and paranoia. They are referred to as florid symptoms. Affective flattening is one of the negative symptoms that contribute to rendering the person inert and unmotivated.
8. A withdrawn client is assessed as having distorted thinking that is not reality based. A nursing diagnosis that should be considered for her would be
A. impaired verbal communication.
B. disturbed thought processes.
C. disturbed sel
B. Disturbed thought processes

Disturbed thought processes is a nursing diagnosis defined as a state in which an individual experiences a disruption in cognitive operations and activities.
9. When a client with schizophrenia hears hallucinated voices saying he is a vile human being, the nurse can correctly assume that the hallucination
A. is a projection of the client's own feelings.
B. derives from neuronal impulse misfiring.
A. is a projection of the client's own feelings.

One theory about derogatory hallucinations is that the content is a projection of the individual's feelings about self. The derogatory hallucinations are an extension of the strong feelings of rejection and lack of self-respect experienced by the individual during the prodromal period.
10. Which side effect of antipsychotic medication has no known treatment?
A. Anticholinergic effects
B. Pseudoparkinsonism
C. Dystonic reaction
D. Tardive dyskinesia
D. Tardive dyskinesia

Tardive dyskinesia is not always reversible with discontinuation of the medication and has no proven cure. Options 1, 2, and 3 often appear early in therapy and can be minimized with treatment.
1. A client with residual schizophrenia is uninterested in community activities. He lacks initiative, demonstrates both poverty of content of speech and poverty of speech, and seems unable to follow the schedule for taking his antipsychotic medication. T
C. neural dysfunction.

Schizophrenia is considered a neurobiological disorder. The course of schizophrenia involves recurrences. With each relapse further deterioration is noted. Residual schizophrenia refers to the disorder when active phase symptoms are no longer present and the individual is left with two or more of the following symptoms: lack of initiative, social withdrawal, impaired role function, marked speech deficits, and odd beliefs.
2. A client with paranoid schizophrenia refuses food. He states the voices are telling him the food is contaminated and will change him from a male to a female. A therapeutic response for the nurse would be
A. "You are safe here in the hospit
C. "I understand that the voices are very real to you, but I do not hear them."

This reply acknowledges the client's reality but offers the nurse's perception that he or she is not experiencing the same thing.
3. A client with disorganized schizophrenia would have greatest difficulty with the nurse
A. interacting with a neutral attitude.
B. using concrete language.
C. giving multistep directions.
D. providing nutritional supplements.
C. giving multistep directions.

The thought processes of the client with disorganized schizophrenia are severely disordered and severe perceptual problems are present, making it extremely difficult for the client to understand what others are saying. All communication should be simple and concrete and may need to be repeated several times.
4. A nursing intervention designed to help a schizophrenic client manage relapse is to
A. schedule the client to attend group therapy.
B. teach the client and family about behaviors associated with relapse.
C. remind the client of the
B. teach the client and family about behaviors associated with relapse.

By knowing what behaviors signal impending relapse, interventions can be quickly invoked when the behaviors occur. The earlier the intervention, the greater the likelihood that a recurrence can be averted.
5. A client with paranoid schizophrenia tells the nurse "I have to get away. The volmers are coming to execute me." The term "volmers" can be assessed as
A. a neologism.
B. derailment.
C. blocking.
D. a delusi
A. a neologism.

A neologism is a newly coined word that has meaning only for the client.
6. When a client with paranoid schizophrenia tells the nurse "I have to get away. The volmers are coming to execute me," an appropriate response for the nurse would be
A. "You are safe here. This is a locked unit and no one can get
D. "It must be frightening to think something is going to harm you."

This response focuses on the client's feelings and neither directly supports the delusion nor denies the client's experience. Option 1 gives global reassurance. Option 2 encourages elaboration about the delusion. Option 3 asks for information that the client will likely be unable to answer.
7. A desired outcome for a client with schizophrenia who has a nursing diagnosis of Disturbed sensory perception: auditory hallucinations related to neurobiological dysfunction would be that the client will
A. ask for validation of reality.
A. ask for validation of reality.

Beginning to question his or her own altered perceptions by seeking input from staff is highly desirable.
8. A client has reached the stable plateau phase of schizophrenia. An appropriate clinical focus for planning would be
A. safety and crisis intervention.
B. acute symptom stabilization.
C. stress and vulnerability assessment.
D. social, vocational, and self-care skills.

During the stable plateau phase of schizophrenia, planning is geared toward client and family education and skills training that will help maintain the optimal functioning of schizophrenic individuals in the community.
9. A client has been receiving antipsychotic medication for 6 weeks. At her clinic appointment she tells the nurse that her hallucinations are nearly gone and that she can concentrate fairly well. She states her only problem is "the flu" that s
C. arrange for the client to have blood drawn for a white blood cell count.

Antipsychotic medications may cause agranulocytosis, the first manifestation of which may be a sore throat and flulike symptoms.
10. The purpose for a nurse periodically performing the Abnormal Involuntary Movement Scale (AIMS) assessment on a persistently mentally ill client who has schizophrenia is early detection of
A. acute dystonia.
B. tardive dyskinesia.
B. tardive dyskinesia.

An AIMS assessment should be performed periodically on clients who are being treated with antipsychotic medication known to cause tardive dyskinesia.

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