Schizophrenia Q 61
A man with a 5-year history of multiple psychiatric admissions is brought to the emergency department by the police. He was found wandering the streets disheveled, shoeless, and confused. Based on his previous medical records and current behavior, he is diagnosed with chronic undifferentiated schizophrenia. The nurse should assign the highest priority to which nursing diagnosis?
A. Anxiety
B. Impaired verbal communication
C. Disturbed thought processes
D. Self-care deficit: Dressing/grooming
Correct Answer: A. Anxiety
For this client, the highest-priority nursing diagnosis is Anxiety (severe to panic-level), manifested by the client’s extreme withdrawal and attempt to protect himself from the environment. The nurse must act immediately to reduce anxiety and protect the client and others from possible injury. Use a non-judgemental, respectful, and neutral approach with the client. Use clear and simple language when communicating with a suspicious client. Be honest and consistent with the client regarding expectations and enforcing rules.
Option B: Impaired verbal communication, manifested by uncommunicativeness. Keep the environment calm, quiet and as free of stimuli as possible. Keep anxiety from escalating and increasing confusion and hallucinations/delusions. Plan short, frequent periods with a client throughout the day. The client might have difficulty processing even simple sentences. Use therapeutic techniques (clarifying feelings when speech and thoughts are disorganized) to try to understand the client’s concerns. Even if the words are hard to understand, try getting to the feelings behind them.
Option C: Disturbed thought processes, evidenced by inability to understand the situation. Attempt to understand the significance of these beliefs to the client at the time of their presentation. Important clues to underlying fears and issues can be found in the client’s seemingly illogical fantasies. Interact with clients on the basis of things in the environment. Try to distract the client from their delusions by engaging in reality-based activities (e.g., card games, simple arts and crafts projects etc). When thinking is focused on reality-based activities, the client is free of delusional thinking during that time. Helps focus attention externally.
Option D: Self-care deficit: Dressing/grooming, evidenced by a disheveled appearance, is an appropriate nursing diagnosis but isn’t the highest priority. Explain the procedures and try to be sure the client understands the procedures before carrying them out. When the client has full knowledge of procedures, he or she is less likely to feel tricked by the staff. Encourage healthy habits to optimize functioning: maintain medication regimen; maintain regular sleep pattern; maintain self-care, and reduce alcohol and drug intake.