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Hesi Case Study Psychosis
Question: Which thought process describes Adam’s inability to leave his apartment because he thinks someone is waiting to kill him? A. Hallucination. B. Phobia. C. Delusions. D. Confabulation.
Answer: C. Delusions.
Answer: B. “You must be concerned, but you are safe here.”
Question: Which term fits the nurse’s observation that Adam looks to the corner of the room and mumbles to himself? A. Delusions. B. Depersonalization. C. Hallucinations. D. Disorientation.
Answer: C. Hallucinations.
Question: When Adam looks around the room and mumbles to himself, how should the nurse respond? A. “How are you feeling?” B. “Are you hearing voices?” C. “Have you been here before?” D. “Tell me what you’re thinking.”
Answer: B. “Are you hearing voices?”
Question: Adam admits that the voices he hears have been getting louder over the past couple of weeks. Which question should the nurse ask Adam next? A. “What helps the voices go away?” B. “How long have you heard voices?” C. “When do the voices get louder?” D. “What do the voices say?”
Answer: D. “What do the voices say?”
Question: Which medications should the nurse anticipate giving Adam after securing a prescription from the healthcare provider? A. Short-acting anxiolytic (benzodiazepines). B. Antipsychotic medication. C. Mood-stabilizing medication. D. Nonbenzodiazepine anxiolytic (antianxiety agent). E. Antidepressant.
Answer: A. Short-acting anxiolytic (benzodiazepines). B. Antipsychotic medication.
Question: Which assessment data provides evidence that Adam can be involuntarily committed to the hospital, if he insists on leaving? A. Past history of suicide attempts. B. Losing 10 pounds in 2 weeks. C. Auditory hallucinations. D. Persecutory delusions.
Answer: B. Losing 10 pounds in 2 weeks.
Answer: D. Take away Adam’s cigarettes and lighter.
Question: Which assessment data are the best indicators of the potential for violence? A. Gender and age. B. Past suicide attempts. C. History of violence. D. Medication compliance. E. Medication noncompliance.
Answer: B. Past suicide attempts. C. History of violence. E. Medication noncompliance.
Answer: A. Detection of substances that may have caused Adam’s delusions and/or hallucinations.
HESI Case Study – Psychiatric-Mental Health Practice Exam
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| At the first meeting of a group of older adults at a daycare center for the elderly, the nurse asks one of the members what kinds of things she would like to do with the group. The older woman shrugs her shoulders and says, "You tell me, you’re the leader." What is the best response for the nurse to make? | B. "Yes, I will be leading this group. What would you like to accomplish during this time?" |
| Over a period of several weeks, one male participant of a socialization group at a community day care center for the elderly monopolizes most of the group’s time and interrupts others when they are talking. What is the best action for the nurse to take in this situation? | C. Allow the group to handle the problem. |
| An 86-year-old female client with Alzheimer’s disease is wandering the busy halls of the extended care facility and asks the nurse, "Where should I stand for the parade?" Which response is best for the nurse to provide? | C. "Let’s go back to the activity room and 1see what is going on there." |
| Physical examination of a 6-year-old reveals several bite marks in various locations on his body. X-ray examination reveals healed fractures of the ribs. The mother tells the nurse that her child is always having accidents. Which initial response by the nurse would be most appropriate? | B. "Tell me more specifically about your child’s accidents." |
| A child is brought to the emergency room with a broken arm. Because of other injuries, the nurse suspects the child may be a victim of abuse. When the nurse tries to give the child an injection, the child’s mother becomes very loud and shouts, "I won’t leave my son! Don’t you touch him! You’ll hurt my child!" What is the best interpretation of the mother’s statements? The mother is | C. projecting her anger. |
| A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse, "I know you are trying to poison me with that food." Which response is most appropriate for the nurse to make? | A. "I’ll leave your tray here. I am available if you need anything else." |
| A 25-year-old female client has been particularly restless and the nurse finds her trying to leave the psychiatric unit. She tells the nurse, "Please let me go! I must leave because the secret police are after me." Which response is best for the nurse to make? | D. "Come with me to your room and I will sit with you." |
| A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows he is not. Which response is best for the nurse to make? | C."I think you’re getting well." |
| A nurse working on a mental health unit receives a community call from a person who is tearful and states, "I just feel so nervous all of the time. I don’t know what to do about my problems. I haven’t been able to sleep at night and have hardly eaten for the past 3 or 4 days." The nurse should initiate a referral based on which assessment? | B. Moderate levels of anxiety. |
| A nurse working in the emergency room of a children’s hospital admits a child whose injuries could have resulted from abuse. Which statement most accurately describes the nurse’s responsibility in cases of suspected child abuse? | C. The nurse should report any case of suspected child abuse. |
| A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting, and drowsiness. What action should the nurse take? | B. Notify the healthcare provider of the symptoms prior to the next administration of the drug. |
| A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates her mannerisms. The nurse knows that the client is using which defense mechanism? | B. Identification |
| The nurse is planning the care for a 32-year-old male client with acute depression. Which nursing intervention bests helps this client deal with his depression? | B. Assist the client in exploring feelings of shame, anger, and guilt. |
| An anxious client expressing a fear of people and open places is admitted to the psychiatric unit. What is the most effective way for the nurse to assist this client? | D. Accompany her outside for an increasing amount of time each day. |
| A client with bipolar disorder on the mental health unit becomes loud, and shouts at one of the nurses, "You fat tub of lard! Get something done around here!" What is the best initial action for the nurse to take? | C. Redirect the client’s energy by asking him to tidy the recreation room. |
| A 35-year-old male client who has been hospitalized for two weeks for chronic paranoia continues to state that someone is trying to steal his clothing. Which action should the nurse implement? | C. encourage the client to actively participate in assigned activities on the unit. |
| On admission, a highly anxious client is described as delusional. The nurse understands that delusions are most likely to occur with which class of disorder? | D. Psychotic |
| A client is admitted with a diagnosis of depression. The nurse knows that which characteristic is most indicative of depression? | D. Negative view on self and future. |
| A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last six months. The client has not gone to work for a month and has been terminated from her job. She has not left the house since that time. This client is displaying symptoms of what condition? | C. Agoraphobia |
| A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad that no one can help me." Which response is best for the nurse to make? | A. "How can I help?" |
| A woman brings her 48-year-old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse. She states that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. The nurse knows that these behaviors are often associated with | A. dissociative disorder |
| A 27-year-old female client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. She is demanding and active. Which intervention should the nurse include in this client’s plan of care? | D. Provide a structured environment with little stimuli |
| The nurse plans to help an 18-year-old female mentally retarded client ambulate the first postoperative day after an appendectomy. When the nurse tells the client it is time to get out of bed, the client becomes angry and tells the nurse, "Get out of here! I’ll get up when I’m ready!" Which response is best for the nurse to make? | D. "I’ll be back in 30 minutes to help you get out of bed and walk around the room." |
| A 46-year-old female client has been on antipsychotic neuroleptics for the past three days. She has had a decrease in psychotic behavior and appears to be responding well to the medication. On the fourth day, the client’s blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. Which action should the nurse initiate? | B. Immediatley transfer the client to ICU |
| A male client is admitted to the psychiatric unit with a medical diagnosis of paranoid schizophrenia. During the admission procedure, the client looks up and states, "No, it’s not MY fault. You can’t blame me. I didn’t kill him, you did." What action is best for the nurse to take? | C. Assess 1the content of the hallucinations by asking the client what he is hearing. |
| A 35-year-old male client on the psychiatric ward of a general hospital believes that someone is trying to poison him. The nurse understands that a client’s delusions are most likely related to his | C. Low self esteem |
| A client who is diagnosed with schizophrenia is admitted to the hospital. The nurse assesses the client’s mental status. Which assessment finding is most characteristic of a client with schizophrenia? | D. Flat affect |
| The nurse is conducting discharge teaching for a client with schizophrenia who plans to live in a group home. Which statement is most indicative of the need for careful follow-up after discharge? | C. "Only my belief in God1 can he1lp me" |
| A 52-year-old male client in the intensive care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveal no significant change and the nurse formulates the diagnosis, "Confusion related to ICU psychosis." Which intervention is best to implement? | C. Cluster care so that brief periods of rest can be scheduled during the day. |
| The nurse observes a female client with schizophrenia watching the news on TV. She begins to laugh softly and says, "Yes, my love, I’ll do it." When the nurse questions the client about her comment she states, "The news commentator is my lover and he speaks to me each evening. Only I can understand what he says." What is the best response for the nurse to make? | A. "What do you believe the news commentator said to you?" |
| A male client with schizophrenia who is taking fluphenazine decanoate (Prolixin decanoate) is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse that he is going on vacation in the Bahamas and will return in 18 days. Which statement by the client indicates a need for health teaching? | A. "When I return from my tropical island vacation, I will1 go to the clinic to get my Prolixin injection" |
| Based on non-compliance with the medication regimen, an adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl (Prolixin) to IM fluphenazine decanoate (Prolixin Decanoate). What is most important to teach the client and family about this change in medication regimen? | C. The effects of alchohol and drug interaction. |
| The nurse suspects child abuse when assessing a 3-year-old boy and noticing several small, round burns on his legs and trunk that might be the result of cigarette burns. Which parental behavior provides the greatest validation for such suspicions? | D. The parents tell the nurse that the child was burned in a house fire which is incompatible with the nurse’s observation of the type of burn. |
| At a support meeting of parents of a teenager with polysubstance dependency, a parent states, "Each time my son tries to quit taking drugs, he gets so depressed that I’m afraid he will commit suicide." The nurse’s response should be based on which information? | D. Careful 1monitoring should be provided during withdrawal from the drugs. |
| The parents of a 14-year-old boy bring their son to the hospital. He is lethargic, but responsive. The mother states, "I think he took some of my pain pills." During initial assessment of the teenager, what information is most important for the nurse to obtain from the parents? | C. If he might have taken any other drugs. |
| The nurse should hold the next scheduled dose of a client’s haloperidol (Haldol) based on which assessment finding(s)? | D. fever of 102 F. |
| A 65-year-old female client complains to the nurse that recently she has been hearing voices. What question should the nurse ask this client first? | B. "Are you ever alone when you hear voices?" |
| The charge nurse is collaborating with the nursing staff about the plan of care for a client who is very depressed. What is the most important intervention to implement during the first 48 hours after the client’s admission to the unit? | B. Maintain safety 1in 1the clients milieu. |
| Within several days of hospitalization, a client is repeatedly washing the top of the same table. Which initial intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior? | C. Allow time for the ritualistic behavior, then redirect the client to other activities |
| A female client with depression attends group and states that she sometimes misses her medication appointments because she feels very anxious about riding the bus. Which statement is the nurse’s best response? | D. "What are some ways that you can cope with your anxiety?" |
| A female client refuses to take an oral hypoglycemic agent because she believes that the drug is being administered as part of an elaborate plan by the Mafia to harm her. Which nursing intervention is most important to include in this client’s plan of care? | D. Reassess client’s mental status for thought processes and content |
| The nurse is planning discharge for a male client with schizophrenia. The client insists that he is returning to his apartment, although the healthcare provider informed him that he will be moving to a boarding home. What is the most important nursing diagnosis for discharge planning? | A. Ineffective denial related to situational anxiety. |
| A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. Vital signs are: temperature, 100° F, pulse 100, and BP 142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority nursing diagnosis? | B. Risk for injury related to alcohol detoxification |
| An elderly female client with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, "Take me home. I want my Mommy." Which response is best for the nurse to provide? | B. Tell the client that 1the 11nurse is there and will help. |
| When preparing a teaching plan for a client who is to be discharged with a prescription for lithium carbonate (Lithonate), it is most important for the nurse to include which instruction? | B. "Keep your dietary salt intake consistent." |
| The nurse is preparing to administer phenelzine sulfate (Nardil) to a client on the psychiatric unit. Which complaint related to administration of this drug should the nurse expect this client to make? | A. "My mouth feels like cotton." |
| A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care? | C. Excessive CNS stimulation will be reduced. |
| A client who is known to abuse drugs is admitted to the psychiatric unit. Which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms? | C. Chlordiazepoxide (Librium) |
| A 22-year-old male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric lavage? | C. He is unresponsive to instructions and is unable to cooperate with emetic therapy. |
| A 72-year-old female client is admitted to the psychiatric unit with a diagnosis of major depression. Which statement by the client should be of greatest concern to the nurse and require further assessment? | A. "I will die if my cat dies" |
| A 19-year-old female client with a diagnosis of anorexia nervosa wants to help serve dinner trays to other clients on a psychiatric unit. What action should the nurse take? | C. Suggest another way for this client to participate in the unit’s activities. |
| Which diet selection by a client who is depressed and taking the MAO inhibitor tranylcypromine sulfate (Parnate) indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen? | D. Roast beef, 11baked potato with butter, and iced tea. |
| The nurse is planning care for a 32-year-old male client diagnosed with HIV infection who has a history of chronic depression. Recently, the client’s viral load has begun to increase rather than decrease despite his adherence to the HIV drug regimen. What should the nurse do first while taking the client’s history upon admission to the hospital? | C.Ask the client if he takes St. John’s wort routinely. |
| A young adult male client, diagnosed with paranoid schizophrenia, believes that world is trying poison him. What intervention should the nurse include in this client’s plan of care? | B. Ask one nurse to spend time with the client daily. |
| The community health nurse talks to a male client who has bipolar disorder. The client explains that he sleeps 4 to 5 hours a night and is working with his partner to start two new businesses and build an empire. The client stopped taking his medications several days ago. What nursing problem has the highest priority? | C. Medication management |
| A male client is admitted to a mental health unit on Friday afternoon and is very upset on Sunday because he has not had the opportunity to talk with the healthcare provider. Which response is best for the nurse to provide this client? | A. "Let me call and leave a message for your healthcare provider" |
| A male client with mental illness and substance dependency tells the mental health nurse that he has started using illegal drugs again and wants to seek treatment. Since he has a dual diagnosis, which person is best for the nurse to refer this client to first? | B. His case manager |
| On admission to a residential care facility, an elderly female client tells the nurse that she enjoys cooking, quilting, and watching television. Twenty-fours after admission, the nurse notes that the client is withdrawn and isolated. It is best for the nurse to encourage this client to become involved in which activity? | B. Participate in a group quilting project |
| he wife of a male client recently diagnosed with schizophrenia asks the nurse, "What exactly is schizophrenia? Is my husband all right?" Which response is best for the nurse to provide to this family member? | B. "It is a chemical imbalance in your brain that causes disorganized thinking." |
| A 40-year-old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or phone calls since admission. He reports he has no family that cares about him and was living on the streets prior to this admission. According to Erikson’s theory of psychosocial development, which stage is the client in at this time? | B. Stagnation |
| The nurse should include which interventions in the plan of care for a severely depressed client with neurovegetative symptoms? (Select all that apply.) | A) Permit rest periods as needed. B) Speaking slowly and simply. D) Allow the client extra time to complete tasks. E) Observe and encourage food and fluid intake. F) Encourage mild exercise and short walks on the unit |
| A woman arrives in the Emergency Center and tells the nurse she thinks she has been raped. The client is sobbing and expresses disbelief that a rape could happen because the man is her best friend. After acknowledging the client’s fear and anxiety, how should the nurse respond? | C. "Rape is not limited to strangers and frequently occurs by someone who is known to the victim." |
| Which statement about contemporary mental health nursing practice is accurate? | D. The psychiatric nursing client may be an individual, family, group, organization, or community. |
| The nurse is taking a history for a female client who is requesting a routine female exam. Which assessment finding requires follow-up? | D. "Black-out" after one drink last night on a date. |
| The nurse is assessing the parents of a nuclear family who are attending a support group for parents of adolescents. According to Erikson, these parents who are adapting to middle adulthood should exhibit which characteristic? | B. Increased self-understanding |
| The nurse observes a client who is admitted to the mental health unit and identifies that the client is talking continuously, using words that rhyme but that have no context or relationship with one topic to the next in the conversation. This client’s behavior and thought processes are consistent with which syndrome? | C. Schizophrenia |
| A female client with obsessive-compulsive disorder (OCD) is describing her obsessions and compulsions and asks the nurse why these make her feel safer. What information should the nurse include in this client’s teaching plan? (Select all that apply.) | A) Compulsions relieve anxiety. B) Anxiety is the key reason for OCD. D) Obsessive thoughts are linked to levels of neurochemicals. E) Antidepressant medications increase serotonin levels. |
| A homeless person who is in the manic phase of bipolar disorder is admitted to the mental health unit. Which laboratory finding obtained on admission is most important for the nurse to report to the healthcare provider? | A. Decrease thyroid stimulating hormone level |
| A 30-year-old sales manager tells the nurse, "I am thinking about a job change. I don’t feel like I am living up to my potential." Which of Maslow’s developmental stages is the sales manager attempting to achieve? | A. Self-Actualization |
| The nurse is assessing a client’s intelligence. Which factor should the nurse remember during this part of the mental status exam? | B. Intellegence is influenced by social and cultural beliefs |
| A male client with schizophrenia tells the nurse that the voices he hears are saying, "You must kill yourself." To assist the client in coping with these thoughts, which response is best for the nurse to provide? | A. "Tell yourself that the voices are unreasonable" |
| A male adolescent is admitted with bipolar disorder after being released from jail for assault with a deadly weapon. When the nurse asks the teen to identify his reason for the assault, he replies, "Because he made me mad!" Which goal is best for the nurse to include in the client’s plan of care? The client will | B. control impulsive actions toward self and others |
| An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the nurse to provide? | C. "Go to occupational therapy and start a project." |
| A client, who is on a 30-day commitment to a drug rehabilitation unit, asks the nurse if he can go for a walk on the grounds of the treatment center. When he is told that his privileges do not include walking on the grounds, the client becomes verbally abusive. Which approach should the nurse use? | b. Ask the client to talk about what is causing him to be upset. D. Remind the client of the unit rules. |
| The nurse is leading a "current events group" with chronic psychiatric clients. One group member states, "Clara Barton was my nurse during my last hospitalization. She was a very mean nurse and wasn’t nice to me." Which response is best for the nurse to make? | D. "Clara Barton started the American Red Cross" |
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HESI Case Studies–Psychiatric/Mental Health-Psychosis (Brian Jones) – Flashcards
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- J Family Med Prim Care
- v.7(6); Nov-Dec 2018
Very early-onset psychosis/schizophrenia: Case studies of spectrum of presentation and management issues
Jitender aneja.
1 Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
Kartik Singhai
Karandeep paul.
Schizophrenia occurs very uncommonly in children younger than 13 years. The disease is preceded by premorbid difficulties, familial vulnerability, and a prodromal phase. The occurrence of positive psychotic symptoms such as delusions and hallucinations depends on the level of cognitive development of child. Furthermore, at times it is very difficult to differentiate the psychopathology and sustain a diagnosis of schizophrenia in view of similarities with disorders such as autism, mood disorders, and obsessive compulsive disorders. Here, we present three case studies with varying presentation of childhood-onset psychosis/schizophrenia and associated management issues.
Introduction
Schizophrenia is a chronic severe mental illness with heterogeneous clinical profile and debilitating course. Research shows that clinical features, severity of illness, prognosis, and treatment of schizophrenia vary depending on the age of onset of illness.[ 1 , 2 ] Hence, age-specific research in schizophrenia has been emphasized. Although consistency has been noted in differentiating early-onset psychosis (onset <18 years of age) and adult-onset psychosis (onset >18 years), considerable variation is observed with regard to the age of childhood-onset schizophrenia or very early-onset psychosis/schizophrenia (VEOP/VEOS).[ 2 , 3 ] Most commonly, psychosis occurring at <13 years of age has been considered to be of very early onset and that between 13 and 17 years to be of adolescent onset.[ 4 ] Furthermore, VEOS has been considered to be rare and shown to have differing clinical features (including positive and negative symptoms, cognitive decline, and neuroimaging findings), course, and outcome when compared with that of early-onset or adult-onset schizophrenia.[ 3 ] Progress in acknowledgement of psychotic disorders in children in the recent times has led primary care physicians and paediatricians to increasingly serve as the principal identifiers of psychiatrically ill youth. In recent years, there has been substantial research in early intervention efforts (e.g., with psychotherapy or antipsychotic medicines) focused on the early stages of schizophrenia and on young people with prodromal symptoms.[ 5 ] Here, we report a series of cases with very early onset of psychosis/schizophrenia who had varying clinical features and associated management issues.
Case Reports
A 14-year-old boy, educated up to class 6, belonging to a family of middle socioeconomic status and residing in an urban area was brought with complaints of academic decline since 3 years and hearing voices for the past 2 years. The child was born out of a nonconsanguineous marriage, an unplanned, uneventful, but wanted pregnancy. The child attained developmental milestones as per age. From his early childhood, he was exposed to aggressive behavior of his father, who often attempted to discipline him and in this pursuit at times was abusive and aggressive toward him. Marital problems and domestic violence since marriage lead to divorce of parents when the child attained age of 10 years.
The following year, the child and the mother moved to maternal grandparents’ home and his school was also changed. Within a year of this, a decline in his academic performance with handwriting deterioration, and irritable and sad behaviour was noted. Complaints from school were often received by the mother where the child was found engaged in fist fights and undesirable behavior. He also preferred solitary activities and resented to eat with the rest of the family. In addition, a decline in performance of daily routine activities was seen. No history suggestive of depressive cognitions at that time was forthcoming. A private psychiatrist was consulted who treated him with sodium valproate up to 400 mg/day for nearly 2 months which led to a decline in his irritability and aggression. But the diagnosis was deferred and the medications were gradually tapered and stopped. Over the next 1 year, he also started hearing voices that fulfilled dimensions of commanding type of auditory hallucinations. He suspected that family members including his mother collude with the unknown persons, whose voices he heard and believed it was done to tease him. He eventually dropped out of school and was often found awake till late night, seen muttering to self, shouting at persons who were not around with further deterioration in his socialization and self-care. Another psychiatrist was consulted and he was now diagnosed with schizophrenia and treated inpatient for 2 weeks with risperidone 3 mg, olanzapine 2.5 mg, and oxcarbazepine 300 mg/day with some improvement in his symptoms. Significant weight gain with the medication lead to poor compliance which further led to relapse within 3 months of discharge. Frequent aggressive episodes over the next 1 year resulted in multiple hospital admissions. He was brought to us with acute exacerbation of symptoms and was receiving divalproex sodium 1500 mg/day, aripiprazole 30 mg/day, trifluperazine 15 mg/day, olanzapine 20 mg/day, and lorazepam injection as and when required. He was admitted for diagnostic clarification and rationalization of his medications. He had remarkable physical features of elongated face with large ears. Non-cooperation for mental state examination, and aggressive and violent behavior were noted. He was observed to be muttering and laughing to self. His mood was irritable, speech was laconic, and he lacked insight into his illness. We entertained a diagnosis of very early-onset schizophrenia and explored for the possibilities of organic psychosis, autoimmune encephalitis, and Fragile X syndrome. The physical investigations done are shown in Table 1 . Further special investigations in the form of rubella antibodies (serum IgG = 64.12 U/mL, IgM = 2.44 U/mL) and polymerase chain reaction for Fragile X syndrome (repeat size = 24) were normal. His intelligence quotient measured a year ago was 90, but he did not cooperate for the same during present admission. Initially, we reduced the medication and only kept him on aripiprazole 30 mg/day and added lurasidone 40 mg twice a day and discharged him with residual negative symptoms only. However, his hallucinations and aggression reappeared within 2 weeks of discharge and was readmitted. This time eight sessions of bilateral modified electroconvulsive therapy were administered and he was put on aripiprazole 30 mg/day, chlorpromazine 600 mg/day, sodium divalproex 1000 mg/day, and trihexyphenidyl 4 mg/day. The family was psychoeducated about the illness, and mother's expressed emotions and overinvolvement was addressed by supportive psychotherapy. Moreover, an activity schedule for the child was made, and occupational therapy was instituted. Dietary modifications in view of weight gain were also suggested. In the past 6 months, no episodes of violence came to our notice, though irritability on not meeting his demands is persistent. However, poor socialization, lack of motivation, apathy, weight gain subsequent to psychotropic medications, and aversion to start school are still unresolved. Influence of his multiple medications on bone marrow function is an impending issue of concern.
Details of investigations done in the three children
An 11-year-old boy, educated up to class 3, belonging to a rural family of lower socioeconomic status was brought with complaints of academic decline since 2 years, repetition of acts, irritability since a year, and adoption of abnormal postures since 6 months. He was born out of a nonconsanguineous marriage, uneventful birth, and pregnancy. He was third in birth order and achieved developmental milestones at an appropriate age. Since 2 years, he would not attend to his studies, had poor attention, and difficult memorization. He attributed it to lack of friends at school and asked for school change. There was no history of low mood, depressive cognitions, conduct problems, or bullying and he performed his daily routine like his premorbid self at that time. Since a year, he was observed to repeat certain acts such as pacing in the room from one end to another, continuously for up to 1–2 h, with intermittent stops and often insisted his mother to follow the suit, stand nearby him, or else he would clang on her. He prohibited other family members except his mother near him and would accept his meals only from her. He repeatedly sought assurance of his mother if he had spoken everything right. He also washed his hands repeatedly, up to 10–20 times at one time, and was unable to elaborate reason for the same. His mood during that period was largely irritable with no sadness or fearfulness. He mostly wore the same set of clothes, would be forced to take bath or get nails/hair trimmed, and efforts to these were often met with aggression from the patient. Eventually, he stopped going to school and his family sought faith healing. Within the next 5–6 months, his illness worsened. Fixed gaze, reduced eye blinking, smiling out of context, diminished speech, and refusal to eat food were the reasons for which he was brought to us. His physical examination was unremarkable and his mental state examination using the Kirby's method showed an untidy and ill-kempt child, with infrequent spontaneous acts, and occasional resentment for examination. He had an expressionless face, with occasional smiling to self, negativism, and mutism. No rigidity in any of the limb was observed. He was diagnosed with catatonic schizophrenia and probable obsessive compulsive disorder (vs mannerisms). We performed a battery of physical investigation to rule out organic psychosis [ Table 1 ]. He responded to injection lorazepam with which catatonia melted away. He was also prescribed olanzapine up to 15 mg/day, fluoxetine 20 mg/day, and dietary modification and lactulose for constipation. The family left against medical advice with 50%–60% clinical improvement [rating on Bush Francis Catatonia Rating scale (BFCRS) reduced from 10 to 4]. He relapsed within a month of discharge, initially with predominance of the probable obsessive compulsive symptoms. Fluoxetine was further increased to up to 60 mg/day. But within the next 2 months, the catatonic symptoms reappeared and he was readmitted. He had received olanzapine up to 25 mg/day, which was replaced with risperidone. In view of nonresponse to intravenous lorazepam, we administered him five sessions of modified bilateral Electro-convulsive therapy (ECT) (rating on BFCRS reduced from 8 to 0). The family was psychoeducated about the child's illness and the need for continuous treatment was emphasized. He was discharged with up to 80%–90% improvement. At follow-ups, he started participating at farm work of the family, took care of self, with some repetition of acts such as washing of hands, and denied any associated anxiety symptoms. However, efforts to re-enroll in school had been futile as the child did not agree for it. He has been maintaining at the same level since 6 months of discharge.
A 7-year-old girl, student of second class, belonging to a high socioeconomic status family living in an urban locality was brought with complaints of academic decline, irritability, and abnormal behavior for the past 9 months. The child was born out of a nonconsanguineous marriage, is first in order, and was a wanted child. Maternal health during pregnancy was normal, but the period of labor was prolonged beyond 18 h, so a lower segment caesarean section was performed. There was no history of birth-related complications and the child's birth weight was 2.80 kg. The child attained developmental milestones as per age. The child had a temperament characterized by high activity levels, below average threshold of distractibility, average ability to sustain attention and persist, easy to warm up, adaptation to new situations, and regular bowel and bladder habits. She was enrolled in school at the age of 4 years and progressed well till 9 months back when a decline in her academic interest was observed by her class teacher. Deterioration of her handwriting skills and avoidance of group activities in school were observed. Similarly, at home persistent irritable behavior was seen and her play activities with her siblings reduced. However, her biofunctions were normal during this period.
One month prior to visiting us, she started insisting on wearing the same dress. She wore the same colored or at times the same dress which she would not take off even at bed or bath time. In addition, a change in her mood from largely irritable to cheerful was noted. Her activity levels were increased and it would be difficult to make her sit quietly in class. Her speech output was more than her usual self and she talked incessantly. Her sleep duration also decreased and she started getting up 3–4 h earlier than her usual routine. In view of these symptoms, her family made first contact with us. Her physical examination was normal and mental state examination revealed her to be cheerful, overactive, and difficult to interrupt. She sang and danced during the interview. We diagnosed her with acute mania on the basis of clinical evaluation and assessment on MINI Kid 6.0.[ 6 ] The details of her physical examination are depicted in Table 1 . She was initially treated with olanzapine 5 mg/day which was later on increased to 10 mg/day. However, no response was observed with it in the next 2 weeks, so it was cross tapered with sodium valproate which was built up to 400 mg/day. She improved by nearly 50%, but her mood still remained cheerful/irritable. She did not resume her school and was brought irregularly for the follow-up. Within the next 2 months, she also started muttering to herself and made certain abnormal gestures. She often feared staying alone, or while going to bed insisted the lights to be kept on and ask someone to accompany her in the toilet unlike her previous self. When asked, she reported seeing a lady in white clothes, with no other details. She stopped asking for food on her own and remained lost in her fantasy world. However, her interest in dressing and appreciating herself in mirror persisted. Her mood during this period was mostly labile and often changed from cheerful to sad or irritable. As per the family, the medications were continued as advised. So in view of the emerging picture, the diagnosis was revised to schizo-affective disorder, and in addition to hike in dose of sodium valproate to 500 mg/day, risperidone 2 mg/day was also added. However, even after 8 weeks of treatment with this combination with hike of risperidone to 4 mg/day, there was no relief. The child is still symptomatic, does not go to school, and has significant dysfunction. Psychosocial intervention in the form of psychoeducation, activity scheduling for the child, and occupational therapy has been instituted in addition to the existing treatment regimen, but results are yet to be seen.
The older concept of neurodegenerative etiology of schizophrenia has been superseded by evolving neurodevelopmental nature of this disease. The latter has been attributed to initiation of the underlying pathophysiological processes long before the onset of clinical disease and interaction of the various genetic and environmental factors. The more accommodating theorist propose schizophrenia to be of neurodevelopmental in origin which in turn speeds the process of neurodegeneration.
On clinical front, VEOS is associated with a more insidious onset, prominent negative symptoms, auditory hallucinations, poorly formed delusions which is in part due to less developed cognitive abilities.[ 7 ] The presence of history of speech and language delay as well as motor development deficits have been observed in major studies on childhood-onset schizophrenia, be it the Maudsley early-onset schizophrenia project or the NIMH study.[ 8 , 9 ] Premorbid deficits in social adjustments and presence of autistic symptoms have also been shown. Moreover, the early onset of psychosis is associated with poor prognosis, worse overall functioning, and multiple hospitalizations.[ 7 ] The duration of untreated psychosis in childhood-onset psychosis has been shown to be smaller in hospital-based studies[ 10 ] and larger in community settings.[ 11 ] In addition, the presence of comorbidities and an organic etiology or history of maternal illness during pregnancy is a common finding in VEOS.[ 10 ] In addition, obsessive compulsive symptoms are frequently observed in first-episode drug-naive schizophrenia patients and have a poorer outcome, more severe impairment of social behavior, and lower functioning.[ 12 ] However, in many instances it is very difficult to differentiate the obsessive compulsive symptoms from the motor symptoms of schizophrenia such as stereotypy and mannerisms and varying degree of insight.[ 13 ]
In the present case series, all the children had an insidious onset of illness, with initial symptom of academic decline, and poorly formed psychotic symptoms/psychotic-like experiences. All the children reported here had dropped out of school, showed a shift in their interests, withdrew from social circle, appeared to be distant, had impaired self-care, and often lacked concern for others along with a range of mood disturbances. All these symptoms fit into the classical description of prodromal symptoms of schizophrenia.[ 14 ] In contrast to available evidence, no history of motor, speech, or language delay was noted in any of the child. Furthermore, no history suggestive of autistic features or problems in social adjustments prior to onset of illness was forthcoming.
However, the diagnosis of schizophrenia could be clearly made in the first case, while the second child had predominant catatonic and probably obsessive compulsive symptoms. It is difficult to ascertain the diagnosis of schizophrenia on the basis of presence of only catatonic symptoms and no delusions and hallucinations or negative symptoms as required by Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition or International Classification of Diseases, Tenth Revision. However, it is very difficult to sustain any other diagnosis for the second child. In the third child, the illness has been evolving and the clinical picture changed from predominant mood symptoms to psychotic-like experiences at later stage. Therefore, at present a diagnosis of schizo-affective disorder is entertained. We could not find any possible organic etiology in any of the three cases with the best of our efforts.
With provision of pharmacological and psychosocial treatment in accordance to the available treatment guidelines,[ 15 ] remission was not achieved in two of the three children. Currently, the available evidence also suggests that the prognosis of childhood-onset schizophrenia is mainly poor as it disrupts the social and cognitive development and thus nearly two-third of children do not achieve remission.[ 16 ] On a positive note, we have been able to retain all the children in treatment.
Other issues faced by the families of three children and the treating team are briefly discussed below. In countries like India, where significant expenses are born by patients/family, associated stigma, limited social services, and the anti-psychotic related adverse effects raise the burden of care exponentially. In 2/3 index patients, the family bore the costs of special investigations, which was not possible in the second child and led to financial difficulties for the single mother of the first child. Adding on, the availability of rehabilitation services for children with major mental illnesses is scarce in various parts of our country. Furthermore, we successfully used ECT for management of acute disturbance in two of the three patients prior to the notification of Mental Health Care Act, 2017 that prohibits its use in minors. The case series also put forward a strong case for strengthening and sensitizing primary care physicians and pediatricians in identifying and treating cases of VEOP, since they are more likely to be the first points of contact with patients of the discussed age group. In view of the duration of untreated psychosis being a very eloquent prognostic factor for VEOP and the symptomatology of the same showing significant heterogeneity, armoring primary care physicians and pediatricians with the right skills to identify, treat, or refer patients with VEOP, especially in the prodromal period, might profoundly contribute in decreasing the morbidity and improving prognosis. Citing this lacuna which could be filled and used to our advantage, Stevens et al .[ 17 ] elaborated and discussed various questions which practitioners might find useful.
Childhood-onset schizophrenia is a rare occurrence. The current case series highlights differing clinical presentation of VEOS/VEOP in children and adolescents. Certain other issues pertinent to the management of VEOS/VEOP are also touched upon in this article. With the early recognition of childhood mental health illnesses, we need to build and strengthen ample child and adolescent mental health services in India.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest.
There are no conflicts of interest.
Acknowledgement
The authors thank Dr. Sonam Arora, MD, DNB (Pathology), for providing assistance in laboratory investigations and article writing.
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HESI Case Study Psychosis. A client is accompanied to the emergency department (ED) by several police officers and a caseworker. The caseworker called the police to enter the client's apartment because the client refused to answer the door. The caseworker brings some medication bottles from the client's apartment and reports that 4 months ago ...
Study with Quizlet and memorize flashcards containing terms like Which thought process describes the client's inability to leave his apartment because he thinks someone is waiting to kill him? A. Hallucination. B. Phobia. C. Delusions. D. Confabulation., When the client explains that someone has been following him and is waiting outside the door of the ED, how should the nurse respond ...
Demographic variables such as gender and age are variables for predicting violence when assessing the client with psychosis. b. past suicide attempts. Past suicide attempts are indicators of violence toward self. c. history of violence. The best single predictor of violence is a past history of violence.
Elsevier case study Psychosis - correct answers and rationales post result begin again correct review your results from at 5:41 pm pst correct incorrect. Skip to document. ... HESI - Case Study Alzheimer's Disease (Early Onset) Intro to Nursing 100% (21) 3. Drug Suffixes Cheat Sheet (Sorted by Drug Type)
HESI Case Study: Schizophrenia Sam Harris Study 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'.
Answer: A. Short-acting anxiolytic (benzodiazepines). B. Antipsychotic medication. Question: Which assessment data provides evidence that Adam can be involuntarily committed to the hospital, if he insists on leaving? A. Past history of suicide attempts. B. Losing 10 pounds in 2 weeks.
Difficulty sleeping at night. C. Feelings of depression. D. Stabilize client's mood. The nurse understands that a client with schizophrenia will experience which benefit from fluphenazine decanoate (Prolixin decanoate) if it is administered intramuscularly? A. Prevent more extrapyramidal side.
Mental Health HESI Final Exam Blueprint. Other 93% (15) 8. Review - Exam 3 - Mental Health. ... Case Study. 2 pages 2022/2023 100% (1) 2022/2023 100% (1) Save. Completesara lin Med Card Template Standard Final. ... David Carter was diagnosed with schizophrenia 10 years ago, and he was stable on his medications until he recently stopped taking ...
A) Talk to the client outside the group about his behavior during group meetings. B) Remind the client to allow others in the group a chance to talk. C) Allow the group to handle the problem. D) Ask the client to join another group. C. Allow the group to handle the problem.
C. Monitor for agranulocytosis. Question 13. A. Sensory-perceptual alteration related to withdrawal into self. Question 14. Consistency. Question 15. The purpose and side effects of psychotropic medications. This allows you to double check your answers. That way you can spend more time on the rationals and less time having to retake it for a 100%.
Use Case Studies in Clinical: • Case studies can be used as a post- conference activity in the clinical setting. • Case studies can also be used for virtual patient care experiences. Use Case Studies as a part of remediation: • Work with students to identify areas of weakness (either the HESI report or faculty made exam) and complete ...
side the door of the ED, how should the nurse respond? "You must be concerned, but you are safe here," 3. Which term fits the nurse's observation that the client looks to the corner of the room and mumbles to himself? Hallucinations 4. When the client looks around the room and mumbles to himself, how should the nurse respond? "Are you hearing voices?" 5. The client admits that the voices he ...
the door of the ED, how should the nurse respond? A. "Believe me. No one has followed you here." B. "You must be concerned, but you are safe here." C. "The police will make sure no one is out there." D. "Why do you think that someone is out there?" CORRECT ANSWER B. "You must be concerned, but you are safe here." Which term fits the nurse's observation that Adam looks to the corner of the room ...
Use your knowledge and apply key concepts to realistic patient care scenarios. HESI Case Studies provide real-world patient care scenarios accompanied by application-based questions and rationales that will help you learn how to manage complex patient conditions and make sound clinical judgments. Questions cover nursing care for patients with a wide variety physiological and psychosocial ...
Elsevier Schizophrenia - Case Study - with rationales post result begin again correct review your results from at 12:22 pm pst correct incorrect question of 38. Skip to document. ... HESI - Case Study Alzheimer's Disease (Early Onset) Intro to Nursing 100% (21) 3. Drug Suffixes Cheat Sheet (Sorted by Drug Type)
Thoughts of harm to self or others. Study with Quizlet and memorize flashcards containing terms like Client continues to explain that someone has followed him to the ED and is waiting outside. Which thought process describes the client's inability to leave his apartment because he thought someone was wanting to kill him?, Phobia is ...
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There are five types of schizophrenia specified in the DSM-IV-TR, which is a diagnostic manual prepared by the American Psychiatric Association that provides diagnostic criteria for all psychiatric disorders. ... Fundamentals HESI Study Guide. Fundamentals of nursing 98% (203) 9. Psych HESI Study Guide. Behavioral Health 100% (28) 14.
FlowerPower1001. A client is brought to the emergency department by the police after being violent at home. The client has multiple past hospitalizations and treatment for schizophrenia. The client believes that the healthcare providers are FBI agents and that the client's apartment is a site for slave trading.
Introduction. Schizophrenia is a chronic severe mental illness with heterogeneous clinical profile and debilitating course. Research shows that clinical features, severity of illness, prognosis, and treatment of schizophrenia vary depending on the age of onset of illness.[1,2] Hence, age-specific research in schizophrenia has been emphasized.Although consistency has been noted in ...
RN Hesi Case Study - Psychosis Question and answers correctly solved 2023/2024. Course. HIM. Institution. HIM. RN Hesi Case Study - Psychosis Question and answers correctly solved 2023/2024Which thought process describes the client's inability to leave his apartment because he thinks someone is waiting to kill him? A. Hallucination.
HESI - Case Study Aortic Regurgitation Corrc; Related Studylists Nclex Study Hesi. Preview text. Open. Post Result 96%. Correct. Let's review your results from 12/23/2021 at 10:01 pm PST. Question 1 of 27. Which is the best response by the nurse to the client's statement? Begin again. Correct Incorrect.