# A nurse is assessing a 35-year-old client who was recently admitted to the psychiatric unit with a diagnosis of schizophrenia. Which assessment finding would be most indicative of a positive symptom of schizophrenia?

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> subject: Mental Health

## 문제

A nurse is assessing a 35-year-old client who was recently admitted to the psychiatric unit with a diagnosis of schizophrenia. Which assessment finding would be most indicative of a positive symptom of schizophrenia?

## 보기

1. The client sits motionless and does not respond to questions for extended periods
2. The client demonstrates poor personal hygiene and appears disheveled
3. The client shows little emotional expression and speaks in a monotone voice
4. The client reports hearing voices telling them that people are plotting against them **✔ 정답**

**정답: 4**

## 해설

Positive symptoms involve abnormal experiences like hallucinations or delusions. Hearing voices of persecution is a classic positive symptom, while other options represent negative symptoms.

## 심화 해설

Core Nursing Explanation
**Key Concept Analysis**: This question tests your ability to differentiate between positive and negative symptoms of Schizophrenia. Positive symptoms are characterized by the presence of abnormal experiences or behaviors that are not typically present in healthy individuals. They are often referred to as "additions" to normal functioning. Negative symptoms involve the diminution or loss of normal functions, such as emotional expression, motivation, or speech.

**Answer Rationale**: Key Point! The correct answer is option 4 because it describes a hallucination (auditory) with a delusion of persecution. Hallucinations and delusions are the hallmark positive symptoms of schizophrenia. The client is experiencing something that is not real (voices) and holding a false, fixed belief (people are plotting against them).

**Distractor Analysis**: Watch out for confusion! Options 1, 2, and 3 all describe negative symptoms. Option 1 describes avolition (lack of motivation) and possibly catatonia. Option 2 describes self-neglect, a common manifestation of avolition and apathy. Option 3 describes flat affect (reduced emotional expression) and alogia (poverty of speech), both core negative symptoms.

**Related Concepts**: Understanding this distinction is crucial for planning care. Positive symptoms often respond better to antipsychotic medications. Negative symptoms are more challenging to treat and are more strongly associated with long-term functional impairment. Assessment must be thorough to identify both types, as they guide treatment and nursing interventions focused on reality orientation, safety (for command hallucinations), and social skills training (for negative symptoms).

Concept Summary

| Category | Definition | Examples |
| --- | --- | --- |
| Positive Symptoms | Additions to normal behavior/experience | Hallucinations, Delusions, Disorganized speech/thought, Bizarre behavior |
| Negative Symptoms | Loss or diminution of normal functions | Flat affect, Alogia, Avolition, Anhedonia, Asociality |

Side-by-Side Comparison!

| Symptom Type | Clinical Presentation | Nursing Focus |
| --- | --- | --- |
| Hallucination (Positive) | Client reports hearing voices (auditory most common), seeing things. May talk to self, appear distracted. | Assess content (are they command hallucinations?). Provide reality orientation. "I do not hear the voices, but I understand they are real to you." Ensure safety. |
| Flat Affect (Negative) | Client shows little facial expression, monotone voice, lack of emotional response to events. | Do not misinterpret as rudeness or disinterest. Engage in non-demanding activities. Model appropriate emotional expressions. |

Anatomy, Physiology & Pharmacology Points
The dopamine hypothesis is a key pathophysiological theory for schizophrenia, suggesting overactivity of dopamine transmission in certain brain pathways (mesolimbic) is linked to positive symptoms. Conversely, underactivity in other pathways (mesocortical) is associated with negative symptoms. First-generation (typical) antipsychotics primarily block D2 dopamine receptors and are more effective for positive symptoms. Second-generation (atypical) antipsychotics also affect serotonin and may have some benefit for negative symptoms.

Memory Tips
**Positive = "Added"** (Think: You ADD hallucinations and delusions).

**Negative = "Subtracted"** (Think: You SUBTRACT emotion, motivation, speech).

**Mnemonic for Negative Symptoms: The 5 A's**: **A**ffect (flat), **A**logia, **A**volition, **A**nhedonia, **A**sociality.

High-Frequency NCLEX Topics
Differentiating positive vs. negative symptoms is a **high-yield** topic. NCLEX often presents a scenario and asks you to identify the symptom type or prioritize care. For a client experiencing command hallucinations (a positive symptom telling them to harm self/others), **safety is always the top priority**.

Watch Out for Question Variations!
*   **From Symptom to Intervention:** "The nurse is caring for a client with schizophrenia who states, 'The voices are telling me I'm worthless.' Which nursing response is most therapeutic?"
*   **From Symptom to Medication:** "A client with schizophrenia exhibits social withdrawal and poor hygiene. The nurse understands these negative symptoms are *least* likely to improve with which class of medication?"
*   **Priority Setting:** "A client with schizophrenia is mute, sits rigidly, and has not eaten. The nurse's **priority** action is to..." (This combines catatonia - a motor positive/negative symptom - with a physiological need).

## 임상 시나리오

Nursing Clinical Practice Guide
**Clinical Scenario:** You are the nurse on an inpatient psychiatric unit. Your patient, Jordan, diagnosed with schizophrenia, is pacing in the day room, frequently looking over their shoulder and whispering. When you approach, Jordan says urgently, "They're in the walls again. The voices say the other patients are agents sent to spy on me."
**Nursing Intervention Strategy:**
1.  **Assessment:** First, assess for **safety**. Ask non-threatening, specific questions about the hallucinations: "Are the voices telling you to hurt yourself or anyone else?" Assess Jordan's reality testing: "What do you believe about the other patients?" Simultaneously, perform a quick mental status exam, noting thought process and affect.
2.  **Intervention:** Use therapeutic communication. Validate the feeling without reinforcing the delusion: "I understand that hearing those voices and feeling watched is very frightening. I do not hear the voices, and I see other patients here for treatment. You are safe here on the unit." Provide distraction or move to a quieter, less stimulating environment. Administer prescribed antipsychotic medications as scheduled and monitor for effectiveness and side effects (e.g., extrapyramidal symptoms (EPS), sedation).
3.  **Patient Education & Evaluation:** Over time, educate Jordan on symptom recognition: "These voices are a symptom of your illness, like a fever is a symptom of the flu." Collaborate on a plan for when symptoms increase. Evaluate the reduction in distress and frequency of hallucinatory episodes in response to medication and nursing interventions.
**Patient Safety and Precautions:** Key Point! **Command hallucinations** (voices instructing the patient to act) require immediate intervention to ensure the safety of the patient and others. Never argue with a delusion, as it is a fixed false belief. Arguing increases agitation and damages the therapeutic alliance.

Nursing Procedure & Medication Flow
When administering antipsychotic medications (e.g., Risperidone, Olanzapine):
*   **Assessment:** Check for medication adherence history, baseline vital signs (especially orthostatic BP due to alpha-blockade), and movement disorders.
*   **Administration:** Administer oral doses with food if GI upset occurs. For intramuscular (IM) long-acting injections, use Z-track technique in a large muscle (e.g., ventrogluteal). Rotate sites.
*   **Monitoring:** Monitor for therapeutic effect (decreased agitation, fewer reports of hallucinations) and side effects: Sedation, orthostatic hypotension, anticholinergic effects (dry mouth, constipation), metabolic effects (weight gain, increased blood glucose), and **extrapyramidal symptoms (EPS)** like acute dystonia, akathisia, parkinsonism, and tardive dyskinesia.
*   **Patient Education:** Teach about the importance of adherence, potential side effects, and to rise slowly from sitting/lying. Advise reporting any involuntary muscle movements immediately.

A Word from Your Senior Nurse
"In psychiatry, your most powerful tool is yourself—your calm presence and therapeutic communication. When a patient is experiencing terrifying positive symptoms, they are living in a different reality. Your job isn't to yank them into ours by force (arguing), but to build a bridge of trust. Start by acknowledging their distress. Safety is always paramount, but never underestimate the power of saying, 'I see you're scared. I'm here with you.' That human connection can be more grounding than we realize. For the NCLEX, lock in the positive vs. negative distinction—it's a cornerstone for countless questions."

## 핵심 개념

- **Schizophrenia** — A chronic and severe mental disorder characterized by distortions in thinking, perception, emotions, language, sense of self, and behavior. It involves a combination of positive, negative, and cognitive symptoms.
- **Positive Symptoms** — Symptoms that reflect an excess or distortion of normal functions, such as hallucinations, delusions, disorganized thought/speech, and bizarre behavior.
- **Negative Symptoms** — Symptoms that reflect a diminution or loss of normal functions, such as flat affect, alogia (poverty of speech), avolition (lack of motivation), anhedonia, and asociality.
- **Hallucination** — A sensory perception in the absence of an external stimulus. Auditory hallucinations (hearing voices) are most common in schizophrenia.
- **Delusion** — A fixed, false belief that is not amenable to change in light of conflicting evidence. Common types in schizophrenia include persecutory (being plotted against), referential (belief that random events are directed at oneself), and grandiose delusions.

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