HESI Case Study: Schizophrenia Sam
Harris
Based on this assessment, what is the most important nursing intervention?
Establish rapport and trust.
Assess for hallucinations.
Maintain adequate social space.
Plan to give a PRN antipsychotic. - ANSWER Establish
rapport and trust
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.
What is the most accurate assessment if the client believes that the healthcare
providers are FBI agents and that there are cameras in his apartment to monitor his
moves?
Hallucinations.
Delusions.
Confabulation.
Thought broadcasting. - ANSWER Delusions
Delusions are fixed, false beliefs that the nurse should avoid trying to logically
disprove to the client.
,Which behavior is characteristic of a thought disorder?
Blunted affect.
Irritability.
Lability of mood.
Preoccupation with guilty feelings. - ANSWER Blunted
affect
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.
Mental Status Exam
The nurse completes the mental status exam and records that Sam's grooming and
hygiene are fair. Sam continually paces in the hall and is unable to sit still for
longer than 1 or 2 minutes. His speech is rapid and difficult to follow. He describes
his mood as blase'. His affect is anxious, and his facial expression is blunted. He is
inattentive and appears distracted. - ANSWER
The nurse understands that schizophrenia can be differentiated from psychosis by
which assessment?
Disorganized speech.
Disorganized behavior.
Auditory hallucinations.
Negative symptoms. - ANSWER Negative symptoms
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. - ANSWER Flat affect and social
inattentiveness
Flat affect and social inattentiveness, or "spaciness," are examples of negative
symptoms characteristic of schizophrenia.
Which nursing problem has priority?
Ineffective community coping.
Disturbed thought processes.
Sensory-perceptual disturbance.
Ineffective denial. - ANSWER Disturbed thought
processes
Disturbed thought processes is a priority problem because Sam is delusional.
Medications
Sam is unable to report his current medication regimen, so the nurse contacts his
case worker to find out what medications Sam is taking. Additional information
from the case worker indicates that Sam has been sleeping only 3 to 4 hours each
night for the past few nights. Sam has demonstrated less energy and states that he
feels really bad and pretty down. The case worker reports that Sam was taking
fluphenazine (Prolixin) 5 mg in the morning and 10 mg at bedtime, along with
benztropine (Cogentin) 2 mg BID because he cannot afford the newer
antipsychotics such as olanzapene (Zyprexa). - ANSWER
What is the reason that Prolixin is prescribed for this patient?
Harris
Based on this assessment, what is the most important nursing intervention?
Establish rapport and trust.
Assess for hallucinations.
Maintain adequate social space.
Plan to give a PRN antipsychotic. - ANSWER Establish
rapport and trust
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.
What is the most accurate assessment if the client believes that the healthcare
providers are FBI agents and that there are cameras in his apartment to monitor his
moves?
Hallucinations.
Delusions.
Confabulation.
Thought broadcasting. - ANSWER Delusions
Delusions are fixed, false beliefs that the nurse should avoid trying to logically
disprove to the client.
,Which behavior is characteristic of a thought disorder?
Blunted affect.
Irritability.
Lability of mood.
Preoccupation with guilty feelings. - ANSWER Blunted
affect
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.
Mental Status Exam
The nurse completes the mental status exam and records that Sam's grooming and
hygiene are fair. Sam continually paces in the hall and is unable to sit still for
longer than 1 or 2 minutes. His speech is rapid and difficult to follow. He describes
his mood as blase'. His affect is anxious, and his facial expression is blunted. He is
inattentive and appears distracted. - ANSWER
The nurse understands that schizophrenia can be differentiated from psychosis by
which assessment?
Disorganized speech.
Disorganized behavior.
Auditory hallucinations.
Negative symptoms. - ANSWER Negative symptoms
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. - ANSWER Flat affect and social
inattentiveness
Flat affect and social inattentiveness, or "spaciness," are examples of negative
symptoms characteristic of schizophrenia.
Which nursing problem has priority?
Ineffective community coping.
Disturbed thought processes.
Sensory-perceptual disturbance.
Ineffective denial. - ANSWER Disturbed thought
processes
Disturbed thought processes is a priority problem because Sam is delusional.
Medications
Sam is unable to report his current medication regimen, so the nurse contacts his
case worker to find out what medications Sam is taking. Additional information
from the case worker indicates that Sam has been sleeping only 3 to 4 hours each
night for the past few nights. Sam has demonstrated less energy and states that he
feels really bad and pretty down. The case worker reports that Sam was taking
fluphenazine (Prolixin) 5 mg in the morning and 10 mg at bedtime, along with
benztropine (Cogentin) 2 mg BID because he cannot afford the newer
antipsychotics such as olanzapene (Zyprexa). - ANSWER
What is the reason that Prolixin is prescribed for this patient?
