HESI Case Study: Schizophrenia

A client is brought to the emergency department by the police after being violent at home. The client has multiple past hospitalizations and treatment for schizophrenia. The client believes that the healthcare providers are FBI agents and that the client's apartment is a site for slave trading. The client believes that the FBI has cameras to monitor every move and to broadcast them on TV.

Based on this assessment, what is the most important nursing intervention?

-Establish rapport and trust.

-Assess for hallucinations.

-Maintain adequate social space.

-Maintaining adequate social space

-Plan to give a PRN antipsychotic.

The nurse understands that the client has a thought disorder rather than a mood disorder. Thought disorders include psychosis and schizophrenia.

The nurse assesses that the client's behavior is guarded and suspicious.

Establish rapport and trust.

Rationale: 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.

Which behavior is characteristic of a thought disorder?

-Blunted affect.

-Irritability.

-Lability of mood.

-Preoccupation with guilty feelings.

Blunted affect.

Rationale: 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.

The nurse completes the mental status exam and records that the client's grooming and hygiene are fair. The client continually paces in the hall and is unable to sit still for longer than 1 or 2 minutes. Speech is rapid and difficult to follow. The client's affect is anxious, inattentive, appears distracted, and facial expression is blunted.

The nurse understands that schizophrenia can be differentiated from psychosis by which assessment?

-Disorganized speech.

-Disorganized behavior.

-Auditory hallucinations.

-Negative symptoms.

Negative symptoms.

Rationale: 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?

-Difficulty sitting still.

-Rapid and disorganized speech.

-Flat affect and social inattentiveness.

-Delusional statements.

Flat affect and social inattentiveness.

Rationale: Flat affect and social inattentiveness, or "spaciness," are examples of negative symptoms characteristic of schizophrenia.

What is the most accurate assessment finding if the client believes that the healthcare providers are FBI agents and that there are cameras everywhere monitoring the client?

-Hallucinations.

-Delusions.

-Confabulation.

-Thought broadcasting.

Delusions.

Rationale: Delusions are fixed, false beliefs that the nurse should avoid trying to logically disprove to the client.

Which nursing problem has priority?

-Not able to cope in the community.

-Alteration in thought processes.

-Alteration in sensory perception.

-Denial of problems.

Alteration in thought processes.

Rationale: Disturbed thought processes is a priority problem because the client is delusional.

The client is unable to report the current medication regimen, so the nurse contacts the case worker to find out what medications the client is taking. Additional information from the case worker indicates that the client has been sleeping only 3 to 4 hours each night for the past few nights. The client has demonstrated less energy and reports feeling really bad and pretty down. The case worker reports that the client was taking fluphenazine 5 mg in the morning and 10 mg at bedtime, along with benztropine 2 mg BID because the newer antipsychotics such as olanzapene are too expensive.

The nurse understands that a client with schizophrenia will experience which benefit from fluphenazine decanoate if it is administered intramuscularly?

-Prevent more extrapyramidal side effects.

-Maintain long-term medication compliance.

-Minimize side effects from benztropine.

-Prevent risk of cardiac or renal disease.

Maintain long-term medication compliance.

Rationale: Fluphenazine decanoate is a long-acting medication that is administered as an injection every 1 to 3 weeks to promote compliance with the medication regimen.

What is the reason that fluphenazine decanoate is prescribed for this client?

-Disorganized thoughts.

-Feelings of depression.

-Stabilize client's mood.

-Difficulty sleeping at night.

Disorganized thoughts.

Rationale: 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.

The client refuses treatment and wants to leave the emergency department. The client is admitted involuntarily for 96 hours.

Which client behavior validates the need for involuntary hospitalization?

-Beliefs about FBI surveillance.

-Diagnosis of schizophrenia.

-Violence towards family.

-Guarded and suspicious.

After 96 hours of involuntary commitment, a client must be asked to sign consent for hospitalization.

Violence towards family.

Rationale: Risk for violence toward self or others is a criterion for involuntary hospitalization.

The client is admitted to the mental health unit for 96 hours. The nurse reviews the routine admission laboratory and medication prescriptions and notes that the client will resume the fluphenazine decanoate. The benztropine has not been prescribed.

Which is the nursing priority?

-Monitor the client for medication side effects.

-Obtain a prescription to begin the benztropine.

-Do not give the fluphenazine and document the reason.

-Ask the client about any side effects from the fluphenazine.

Obtain a prescription to begin the benztropine.

Rationale: The nurse should request a prescription for benztropine, which will help prevent the extrapyramidal side effects of the fluphenazine, with the exception of tardive dyskinesia. There is a risk of decreased efficiency of fluphenazine when the client is also taking benztropine.

Which side effects would the nurse most likely observe with fluphenazine, a traditional antipsychotic?

-Blood dyscrasias such as thrombocytopenia.

-High extrapyramidal effects, low anticholinergic effects.

-High anticholinergic effects and low extrapyramidal effects.

-Risk for agranulocytosis, fever, and elevated blood pressure.

High extrapyramidal effects, low anticholinergic effects.

Rationale: Traditional antipsychotics generally have high extrapyramidal effects and low anticholinergic effects.

The nurse asks the client about any allergies to medications. The client reports an allergy to haloperidol. The nurse asks the client to describe the type of reaction experienced, and the client reports a stiff neck that was hard to move.

What type of reaction should the nurse suspect?

-Akathisia.

-Dystonia.

-Parkinsonism.

-Synergistic.

Dystonia.

Rationale: 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.

In addition to the client's thoughts that the FBI had cameras everywhere and that all moves were broadcast on TV, reassessment by the nurse indicates that the client remains suspicious and guarded, with orientation only to day and place. The client claims to be a famous movie star and explains to the nurse that a limousine driver will be there later in the day.

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)?

-Mental status of client.

-Reason that client wants to leave.

-Response to medications.

-Potential danger to self or others.

Potential danger to self or others.

Rationale: Potential danger to self and others is the most important consideration when a client wants to leave the hospital AMA.

How should the nurse respond?

-State that this is unlikely and ask the client what the thought process is behind this.

-Ask the client what will happen if the limousine does not come.

-State that it sounds like the client is anxious to leave.

-Everything is confidential, and doubtful of occurring.

State that it sounds like the client is anxious to leave.

Rationale: 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.

How should the nurse interpret the client's belief about being a famous movie star and that a limousine driver will arrive to get the client later in the day?

-Psychotic thinking.

-Delusional thoughts.

-Flight of ideas.

-Confabulation.

Delusional thoughts.

Rationale: The client's thoughts are delusional because of false beliefs about being a movie star and that a limousine will pick the client up.

In planning this client's care, what is the most important short-term client outcome?

-Interact without expressing delusional thoughts.

-Create a support network within the community.

-Identify at least one symptom management technique.

-Identify actions to take to prevent relapse.

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Interact without expressing delusional thoughts.

Rationale: 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.

During reassessment of the client, the nurse notices that the client sometimes pauses and mumbles something quietly. The client's head tilts to one side and then returns attentively to the nurse.

-Have the client say what thoughts are occurring.

-Get the client to express what feelings are happening.

-Ask if the client about hearing any voices.

-Tell the client about being observed talking to someone.

The client smiles at the nurse but refuses to answer.

Ask if the client about hearing any voices.

Rationale: Tilting the head to one side is a nonverbal cue that the client is hearing voices. The nurse should assess for the presence of auditory hallucinations.

On the third day of hospitalization, the nurse must assign the client to one of the unit groups.

Which group is most therapeutic for the client?

-Structured medication group.

-Unstructured group about personal issues.

-Psychoeducational group about self-esteem.

-Supportive therapy group.

Structured medication group.

Rationale: A structured medication group is the 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.

The client agrees to participate in a group that is scheduled to last for 3 weeks and remains attentive, responding to questions when asked. During the first group, the client shares that the medications cause too many side effects after taking them for a long time.

Based on the client's statement about all the medication side effects, which nursing problem should the nurse document for the group progress note?

-Denial that is unproductive.

-Lack of knowledge.

-Unable to cope.

-Probable difficulty with adherence.

Probable difficulty with adherence.

Rationale: 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.

The following week, another client in the group asks the nurse leader why individuals develop schizophrenia.

Which understanding is most accurate?

-There is an imbalance of the brain neurotransmitters dopamine and serotonin.

-There is a marked increase in brain volume, which causes abnormal functioning.

-Schizophrenia develops when at least one parent or distant relative has schizophrenia.

-This brain disorder has many predisposing factors and a biological basis.

This brain disorder has many predisposing factors and a biological basis.

Rationale: 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 final group session.

How should the nurse explain symptom triggers to the clients?

-Symptom triggers are stressors that lead to increased difficulty handling anger.

-Symptom triggers can be related to health, the environment, or attitudes.

-Symptom triggers are behaviors that lead to medication noncompliance.

-Symptom triggers are stressors caused by hospitalization.

Symptom triggers can be related to health, the environment, or attitudes.

Rationale: 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.

One client in the group asks why do they need to know about symptom triggers.

Which explanations are best? (Select all that apply.)

-Knowing symptom triggers and how to manage them can help prevent relapse.

-Identifying symptom triggers may prevent the risk of violence and promote safety.

-Managing symptom triggers promotes communication with your caseworker.

-Keeping informed about triggers allows you to increase your medications immediately.

-Reducing exposure to triggers helps improve the client's prognosis by minimizing relapses.

-Knowing symptom triggers and how to manage them can help prevent relapse.

Rationale: A client can learn to cope with symptom triggers and prevent relapse and hospitalization.

Identifying symptom triggers may prevent the risk of violence and promote safety.

Rationale: Identifying triggers can prevent the risk of violence, as sometimes triggers lead to violence.

Reducing exposure to triggers helps improve the client's prognosis by minimizing relapses.

Rationale: Minimizing the onset and duration of relapses is believed to improve the prognosis. Early assessment plays a key role in improving the prognosis for persons with schizophrenia.

After 3 weeks of hospitalization, the client continues to be delusional and talking to self. The nurse often finds the client sitting alone in the dining area. The client declines some of the group activities and sits for several hours without initiating any activity. Persistent nursing interventions are required to get the client to perform routine tasks.

Which nursing assessment accurately describes the client's lack of energy?

-Apathy.

-Anhedonia.

-Avolition.

-Affective.

Avolition.

Rationale: Avolition is a lack of energy or drive.

Which nursing problem should be included on the treatment plan?

-Problems with adjustment.

-Isolated socially.

-Anxiety.

-Confusion.

Isolated socially.

Rationale: Social isolation is manifested by behaviors such as the client sitting alone continuously without interacting with others.

The client's healthcare provider decides to discontinue the fluphenazine and begin a new antipsychotic, olanzapine. The client's caseworker is contacted and financial arrangements are made for the client to receive the olanzapine.

-Baseline weight.

-Orthostatic blood pressure.

-Complete blood count.

-Screening for tardive dyskinesia.

Baseline weight.

Rationale: Weight gain occurs with the atypical antipsychotics, especially olanzapine.

The nurse recalls that the atypical antipsychotics have different side effects than traditional antipsychotics.

Which side effect(s) are characteristic of atypical antipsychotics? (Select all that apply.)

-Decreased tardive dyskinesia.

-Less incidence of weight gain.

-Fewer extrapyramidal effects.

-More extrapyramidal effects.

-Insomnia.

-Decreased tardive dyskinesia.

-Fewer extrapyramidal effects.

-Insomnia.

Rationale: Two advantages of the atypical agents are that they are effective in treating negative symptoms and that they are unlikely to cause symptoms of EPS, including tardive dyskinesia. Weight gain, drowsiness, unsteady gait, headache, insomnia, depression, diabetes mellitus, and dyslipidemia are common side effects of atypical antipsychotics.

The nurse understands that an atypical antipsychotic like olanzapine can require what period of time to reach full clinical level?

-2 weeks.

-4 days.

-6 weeks or more.

-2 days.

6 weeks or more.

Rationale: Atypical antipsychotics can take 6 weeks or more to achieve full clinical level. Client should be educated to continue to take medication as prescribed and to report adverse side effects.

The nurse is hopeful that the client will respond favorably to the new antipsychotic. The nurse recalls that another client with schizophrenia was treated with olanzapine without a positive response. When that client failed to respond, several other atypical antipsychotics were given to manage the client's symptoms.

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?

-Clozapine.

-Haloperidol decanoate.

-Fluphenazine decanoate.

-Perfenazine.

Clozapine.

Rationale: When a client has failed to respond to antipsychotic medications or long-acting antipsychotics, clozapine may be initiated. Clozapine is used for clients with schizophrenia who have not responded to other antipsychotics. The potentially serious side effect of agranulocytosis requires that WBC counts be done weekly or every 2 weeks.

After several weeks, the client begins to demonstrate more initiative to attend daily groups without prompting by the nurse. The client 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.

Which speech process should the nurse document on the daily mental status exam record?

-Loose associations.

-Tangential.

-Monotone.

-Poverty of speech.

Poverty of speech.

Rationale: A client who demonstrates poverty of speech gives simple one- or two-word answers to questions, even when the nurse asks an open-ended question.

A client who demonstrates poverty of speech gives simple one- or two-word answers to questions, even when the nurse asks an open-ended question.

Which thought process does this exemplify?

-Concrete thinking.

-Flight of ideas.

-Word salad.

-Thought blocking.

Thought blocking.

Rationale: Thought blocking is the sudden stopping in the client's train of thought or in the middle of a sentence.

The nurse further assesses the client's mental status to determine still having thoughts about FBI agents spying and hiding cameras everywhere. The long-term goal is that the client will not experience delusional thoughts by discharge.

Which intervention by the nurse will best assess if this goal has been met?

-Observe the client for signs of talking to self.

-Talk to the client for at least 20 minutes.

-Ask the client to describe current feelings.

-Ask the client to explain how the medication is helping.

Talk to the client for at least 20 minutes.

Rationale: The nurse should be able to talk to the client without observing the presence of delusional thoughts. This would be evidence that therapy is working and delusions are not evident.

Because the client was violent with family members prior to admission, another long-term goal is that the client will not verbalize the desire to harm self or others.

Which statement will assist the nurse to assess if this goal has been met?

-Review with the client any history of violence.

-Have the client describe relationships with family members.

-Tell the client to express feelings about family members now.

-Ask the client about thoughts about hurting anyone now.

Ask the client about thoughts about hurting anyone now.

Rationale: The nurse should directly ask the client about thoughts of harm.

The client talks to the nurse for nearly 30 minutes without mentioning FBI agents everywhere. When the nurse asks about plans for discharge, the client states wanting to return home, denying having any thoughts of hurting self or others. The treatment team meets to review the client's discharge plan and the response to the new atypical antipsychotic medication. The discharge plan is to discharge the client in 1 week. A criterion for discharge is that the client will attend a weekly wellness group.

What will be the most important group activity to promote wellness in the community?

-Explore symptom management.

-Review education about medications.

-Practice social skills.

-Identify community coping resources.

The nurse plans to teach the group members about symptom management techniques.

Explore symptom management.

Rationale: 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.

What is the most important step the nurse should use to teach about effective symptom management?

-Talk about specific support systems.

-Review current ways to manage symptoms.

-Identify problem symptoms.

-Discuss other ways to manage symptoms.

Identify problem symptoms.

Rationale: Identifying problem symptoms is the first step of effective symptom management. When a client can recognize early and seek support, the client is more likely to need an acute care intervention.

A behavioral intervention that the nurse plans to teach the clients includes ways to cope with symptoms such as hallucinations and delusions.

Which strategy is best for clients who hear voices?

-Identify measures to control auditory hallucinations.

-Smoke more cigarettes.

-Decrease caffeine use.

-Take more medication.

Identify measures to control auditory hallucinations.

Rationale: Strategies such as 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 performing relaxation exercises. This includes focusing on real events.

The nurse plans to talk about relapse prevention.

The client is concerned about experiencing another relapse. Which intervention best promotes effective communication?

-Have the client identify symptom management techniques.

-Explain the importantance of medication compliance.

-Encourage consistant participation with community support.

-Tell the client about the need to maintain healthy living practices.

Explain the importantance of medication compliance.

Rationale: One of the most common causes of relapse relates in some way to medications. Relapse is likely to occur if the clients are not taking their medications as prescribed or stop taking them altogether.

A client in the wellness group states he was taking medications every day and started hearing voices more and had to be hospitalized.

What is the nurse's best response?

-Explain how even when taking medications as prescribed, hallucinations can still happen.

-Suggest that the client may have forgotten to take the medication as prescribed.

-Ask the client how long they have been taking the medications.

-Reinforce that compliance with medications will prevent relapse.

Explain how even when taking medications as prescribed, hallucinations can still happen.

Rationale: The nurse should explain that relapse can occur even if the client has been taking medications as prescribed.

One week later, the client has achieved the long-term goal to be free of delusions and has attended the wellness group to promote wellness in the community. The client's community case worker has been contacted about the discharge plans and the need for transportation to the client's apartment.

What is the greatest benefit of a caseworker for this client?

-Coordinate services for the client.

-Make sure the client takes prescribed medications.

-Empower the client to be independent.

-Provide guidance for disability income.

Coordinate services for the client.

Rationale: The greatest benefit of the case worker is to coordinate services related to housing, finances, and medical appointments, for example.