A patient diagnosed with schizophrenia may demonstrate these positive symptoms (select all that apply) :
Answering questions with nonsensical phrases.
Seeing, hearing, or feeling something that is not really there.
The feeling that external events such as the weather forecast or news story have special meaning for the patient.
Trouble staying on a schedule or finishing what the patient starts.
Inability to socially connect with others.
Correct Answer : A,B,C
Choice A reason : Answering questions with nonsensical phrases is a positive symptom of schizophrenia. It reflects disorganized thinking and speech, which can manifest as incoherence or irrelevance in the patient's verbal communication². This symptom can significantly impair the patient's ability to engage in meaningful conversation and is often one of the more noticeable signs of schizophrenia during an assessment³.
Choice B reason : Seeing, hearing, or feeling something that is not really there, also known as hallucinations, are hallmark positive symptoms of schizophrenia. These sensory experiences occur without an external stimulus and can involve any of the senses, although auditory hallucinations are the most common in schizophrenia². Hallucinations can be extremely distressing for patients and can lead to difficulties in distinguishing reality from delusion³.
Choice C reason : The belief that personal significance is attached to trivial or unrelated external events, known as delusions of reference, is another positive symptom of schizophrenia. Patients may believe that messages are being sent to them through the television, radio, or other public means². This can lead to a profound sense of misunderstanding and isolation as the patient navigates a world they perceive as filled with hidden messages meant specifically for them³.
Choice D reason : While trouble staying on a schedule or finishing tasks can be associated with schizophrenia, it is not considered a positive symptom. These issues are more reflective of the negative symptoms of schizophrenia, which include avolition or the lack of motivation to initiate and complete goal-directed activities⁴.
Choice E reason : An inability to socially connect with others is also not a positive symptom but rather a negative symptom of schizophrenia. Negative symptoms represent a loss or a decrease in the ability to initiate plans, speak, express emotion, or find pleasure in everyday life⁴. Social withdrawal and impaired social interaction are common negative symptoms that can be mistaken for introversion or depression³.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Encouraging interaction with others by having the client share a room might be overwhelming for a client experiencing hypomanic episodes. Hypomania can involve irritability and impulsivity, making shared spaces potentially stressful. It's important to balance social interaction with the need for a controlled environment¹.
Choice B reason: Providing a calm atmosphere by placing the client in a private room can be beneficial for someone experiencing hypomanic episodes. A private room can reduce overstimulation and help manage symptoms like restlessness, agitation, and sleep disturbances. It allows the client to have a quiet space to retreat to, which can be crucial in managing mood swings¹².
Choice C reason: While a cheerful environment may seem beneficial, having bright drapes in the client's room could potentially contribute to overstimulation. Clients with hypomania are often sensitive to environmental stimuli, so it's important to keep the setting subdued to avoid exacerbating symptoms¹.
Choice D reason: Promoting access to activities by assigning the client to a room near the dayroom can be a double-edged sword. While it facilitates engagement in structured activities, which can be therapeutic, it also increases the risk of overstimulation due to the proximity to a potentially busy and noisy area. Careful consideration of the client's current state is necessary when making this decision¹.
Correct Answer is B
Explanation
Choice A reason : While it is important to assure the client, the nurse must first verify that there is a formal DNR order in place to legally honor the client's wishes¹².
Choice B reason : Checking for a DNR order in the medical record is the correct action to ensure that the client's wishes regarding resuscitation are documented and will be followed by all healthcare providers¹².
Choice C reason : Asking about a healthcare proxy is important, but it is secondary to confirming that the client's wishes are documented in the medical record through a DNR order or advance directives¹².
Choice D reason : Verifying a signed copy of the advance directives is crucial, but the immediate step is to check for a DNR order, which is specifically related to the client's request not to be resuscitated¹².
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