NU473 Week 6 HESI Case Study Evolve Elsevier: Schizophrenia - 38 Questions Rated A+

NU473 Week 6 HESI Case Study Evolve Elsevier: Schizophrenia - 38 Questions Rated A+ Nursing Interventions and Assessments 1. Most Important Nursing Intervention: - Establish rapport and trust. - Rationale: Building rapport is vital for clients who are suspicious and guarded due to their delusions. Establishing trust helps facilitate communication and can contribute to a more therapeutic environment. 2. Characteristic of a Thought Disorder: - Blunted affect. - Rationale: Blunted affect is associated with the negative symptoms of thought disorders, particularly schizophrenia, indicating a lack of emotional expression. 3. Differentiating Schizophrenia from Psychosis: - Negative symptoms. - Rationale: Schizophrenia is characterized by negative symptoms such as flat affect, social withdrawal, and lack of motivation, which differentiate it from other psychotic disorders. 4. Finding Depicting Negative Symptoms of Schizophrenia: - Flat affect and social inattentiveness. - Rationale: These signs represent negative symptoms that affect a client's ability to express emotions and engage socially. 5. Accurate Assessment of Client's Beliefs: - Delusions. - Rationale: Delusions are defined as fixed, false beliefs that are resistant to reason or confrontation with actual facts. In this case, the client believes healthcare providers are FBI agents, which is indicative of delusional thinking. 6. Priority Nursing Problem: - Alteration in thought processes. - Rationale: This problem takes precedence as disturbed thought processes resulting from delusions can significantly impede the client’s functioning and safety. Medication Management 7. Benefit of Fluphenazine Decanoate: - Maintain long-term medication compliance. - Rationale: Fluphenazine decanoate is a long-acting injectable antipsychotic, administered every 1 to 3 weeks, which helps ensure that the client remains compliant with their medication regimen, reducing the risk of relapse. 8. Reason for Ordering Fluphenazine Decanoate: - Disorganized thoughts. - Rationale: This medication is effective in addressing disorganized and delusional thinking associated with schizophrenia, thereby helping to stabilize the client's thought processes. 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. Which client behavior validates the need for involuntary hospitalization? o Beliefs about FBI surveillance. o Diagnosis of schizophrenia. o Violence towards family. o Guarded and suspicious. o Violence towards family. · 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 orders and notes that the client will resume the fluphenazine decanoate. The benztropine has not been prescribed. Which nursing action is best? o Monitor the client for medication side effects. o Obtain a prescription to begin the benztropine. o Do not give the fluphenazine and document the reason. o Ask the client about any side effects from the fluphenazine. o Obtain a prescription to begin the benztropine. · The nurse should request an order 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? o Blood dyscrasias such as thrombocytopenia. o High extrapyramidal effects, low anticholinergic effects. o High anticholinergic effects and low extrapyramidal effects. o Risk for agranulocytosis, fever, and elevated blood pressure. o High extrapyramidal effects, low anticholinergic effects. · Traditional antipsychotics generally have high extrapyramidal effects and low anticholinergic effects. The nurse asks the client about any allergies to medications. Client states he has an allergy to haloperidol. The nurse asks the client to describe the type of reaction experienced and the client reports a stiff neck which is hard to move. What type of reaction should the nurse suspect this is? o Akathisia. o Dystonia. o Parkinsonism. o Synergistic. o Dystonia. · 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. 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)? o Mental status of client. o Reason that client wants to leave. o Response to medications. o Potential danger to self or others. o Potential danger to self or others. · Potential danger to self and others is the most important consideration when a client wants to leave the hospital. How should the nurse respond? o State that this is unlikely and ask the client what the thought process is behind this. o Ask the client what will happen if the limousine does not come. o State that it sounds like the client is anxious to leave. o Everything is confidential, and doubtful of occurring. o State that it sounds like the client is anxious to leave. · 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?