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19. A patient diagnosed with schizophrenia has received fluphenazine decanoate twice a month for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patient’s neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect?

a. Agranulocytosis b. Tardive dyskinesia c. Tourette’s syndrome d. Anticholinergic effects

ANS: B

Fluphenazine decanoate is a first-generation antipsychotic medication. Tardive dyskinesia is a condition involving the face, trunk, and limbs that occurs more frequently with first-generation antipsychotics than second or third generation. Involuntary movements, such as tongue thrusting; licking; blowing; irregular movements of the arms, neck, and shoulders; rocking; hip jerks; and pelvic thrusts, are seen. These symptoms are frequently not reversible even when the drug is discontinued. The scenario does not present evidence consistent with the other disorders mentioned. Agranulocytosis is a blood disorder. Tourette’s syndrome is a condition in which tics are present. Anticholinergic effects include dry mouth, blurred vision, flushing, constipation, and dry eyes.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

REF: Pages 12-51, 83 (Table 12-4) TOP: Nursing Process: Evaluation

MSC: Client Needs: Physiological Integrity a. “Why are you laughing?” b. “Please share the joke with me.” c. “I don’t think I said anything funny.” d. “You’re laughing. Tell me what’s happening.”

20. A nurse sits with a patient diagnosed with schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the nurse’s most therapeutic response.

ANS: D

The patient is likely laughing in response to inner stimuli, such as hallucinations or fantasy. Focus on the hallucinatory clue (the patient’s laughter) and then elicit the patient’s observation. The incorrect options are less useful in eliciting a response: no joke may be involved, “why” questions are difficult to answer, and the patient is probably not focusing on what the nurse said in the first place.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 12-16, 44, 45, 95 (Box 12-3)

TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity a. Auditory hallucinations b. Delusions of grandeur c. Poor personal hygiene d. Psychomotor agitation

21. The nurse assesses a patient diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia?

ANS: C

Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning. The distracters are positive symptoms of schizophrenia. See relationship to audience response question.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 12-4, 17, 72 (Table 12-2) TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion b. Auditory hallucinations, ideas of reference, thought insertion, and broadcasting c. Stereotyped behavior, echopraxia, echolalia, and waxy flexibility d. Loose associations, concrete thinking, and echolalia neologisms

22. What assessment findings mark the prodromal stage of schizophrenia?

ANS: A

Withdrawal, misinterpreting, poor concentration, and preoccupation with religion are prodromal symptoms, the symptoms that are present before the development of florid symptoms. The incorrect options each list the positive symptoms of schizophrenia that might be apparent during the acute stage of the illness.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 12-3 to 5, 15, 92 (Box 12-1) TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity a. Poverty of content b. Concrete thinking c. Neologisms d. Paranoia

23. A patient diagnosed with schizophrenia says, “Contagious bacteria are everywhere. When they get in your body, you will be locked up with other infected people.” Which problem is evident?

ANS: D

The patient’s unrealistic fear of harm indicates paranoia. Neologisms are invented words. Concrete thinking involves literal interpretation. Poverty of content refers to an inadequate fund of information.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 12-20, 74 (Table 12-3) TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity a. Skin care techniques b. Scheduling a colonoscopy c. Weight management strategies

24. A patient diagnosed with schizophrenia begins a new prescription for ziprasidone. The patient is 5'6'' and currently weighs 204 lbs. The patient has dry flaky skin, headaches about twice a month, and a family history of colon cancer. Which intervention has the highest priority for the nurse to include in the patient’s plan of care?