# Situation: A 24-year-old man with schizophrenia is admitted to the psychiatric unit. He stopped taking his antipsychotic medicine 2 months ago. For weeks he has stayed in his room, has rarely bathed, and has stopped going to work. He has no history of violence. On the second day he has still not bathed or changed his clothes and says he has no energy to do it. Which approach BEST promotes his hygiene?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629981  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 24-year-old man with schizophrenia is admitted to the psychiatric unit. He stopped taking his antipsychotic medicine 2 months ago. For weeks he has stayed in his room, has rarely bathed, and has stopped going to work. He has no history of violence.

On the second day he has still not bathed or changed his clothes and says he has no energy to do it. Which approach BEST promotes his hygiene?

## 보기

1. Wait until he says he feels ready, then offer the bath
2. Bathe and dress him fully so the task is done quickly
3. Tell him that other clients will avoid him if he smells
4. Set a fixed time each day and cue him step by step **✔ 정답**

**정답: 4**

## 해설

Avolition leaves the client unable to start and complete self-care, so the nurse builds a predictable routine at the same time each day and gives simple, step-by-step prompts while he does as much as he can himself. Waiting for motivation lets the deficit continue, doing the task for him increases dependence, and shaming raises withdrawal.

## 심화 해설

Core deficit in this scenario

The presentation points to avolition, a negative symptom of schizophrenia characterized by reduced drive to initiate and persist in goal-directed activity. The client has not bathed, changed clothes, or gone to work for weeks, and on the second hospital day he still reports having no energy. This is not laziness or defiance; it reflects a neurobiologically driven motivational deficit that makes self-care tasks feel overwhelming and difficult to start [4].

Because avolition impairs initiation and sequencing, the nurse must supply the external structure the client cannot generate internally. A fixed daily time creates predictability, and step-by-step cues break a complex task such as bathing into manageable components. The client should still do as much as he can himself, preserving autonomy and preventing dependence.

Why the other options fail

| Option | Problem | Underlying principle |
| --- | --- | --- |
| 1. Wait until he feels ready | Motivation may not return spontaneously | Avolition is persistent; waiting allows the deficit to continue and hygiene to deteriorate |
| 2. Bathe and dress him fully | Removes client participation | Doing the task for him increases dependence and undermines self-efficacy |
| 3. Tell him others will avoid him | Shaming and social threat | Negative feedback worsens withdrawal and damages the therapeutic relationship |
| 4. Fixed time and step-by-step cues | External structure compensates for internal deficit | Predictable routine plus graduated prompting supports initiation while preserving autonomy |

Why structure works: temporal and functional perspectives

Qualitative work with inpatients with schizophrenia highlights that hospitalization disrupts subjective time experience, and recovery involves rebuilding a sense of continuity between past, present, and future [2]. A fixed daily hygiene time is a concrete temporal anchor that helps the client re-establish a predictable rhythm during the day. Rather than waiting for an internal sense of readiness that may not come, the schedule itself becomes the cue for action.

This aligns with broader expert consensus that supporting daily functioning in mental illness requires structured, routine-based strategies embedded in recovery-oriented care, not simply symptom suppression . The nurse’s step-by-step prompting is a psychosocial intervention that scaffolds the client’s executive and motivational capacity without taking over the task.

Empowerment and autonomy

A case report on empowerment-based management in treatment-resistant schizophrenia emphasizes preserving patient autonomy and subjective agency rather than having staff perform tasks for the patient . The correct approach honors this principle: the nurse cues and supports, but the client performs each step he is able to manage. This reduces helplessness and builds confidence for future self-care.

Watch out! In negative-symptom schizophrenia, lack of bathing is rarely a willful refusal. Interpreting it as defiance and responding with pressure or shame will increase withdrawal and damage trust.

Key point! For avolition, the nursing action is to provide external structure: consistent timing, simple verbal cues, and graded participation. Do not wait for motivation, do not do the task for the client, and never use shame as a motivator.References (research sources)

- [2]Perceived temporal reorganization during psychiatric hospitalization among people with schizophrenia: a qualitative interview study.Research articleQin Y, Mao Q, Li H, Zhang F, Wang S, Wang D, Wang J. (2026) · DOI: 10.3389/fpsyt.2026.1869125

- [4]Translational pathways of oxytocin therapy in schizophrenia: bridging negative symptom domains and neural mechanisms.Research articleJi L, Wang X, Li Y, Zhao W, Du X, Gao Y, Li J, Liu S. (2026) · DOI: 10.1038/s41398-026-04145-9

## 임상 시나리오

Promoting Hygiene in Schizophrenia with AvolitionExternal structure compensates for impaired self-initiation
In avolition, the client cannot reliably start or sequence self-care, so the nurse supplies external structure. Set a fixed time each day for bathing and give simple, step-by-step cues while the client does as much as possible himself.

Break the task into small components such as turning on water, gathering soap, and washing one body area at a time. A predictable routine reduces decision-making load and supports initiation without taking over the task.

CautionDo not wait for motivation, perform the task fully for the client, or use shame about odor or social rejection. These approaches allow deterioration, increase dependence, and worsen withdrawal.

## 핵심 개념

- **Avolition** — A negative symptom of schizophrenia marked by reduced drive to initiate and persist in goal-directed activities such as self-care.
- **Negative symptoms** — Deficits in normal functions, including avolition, alogia, anhedonia, asociality, and blunted affect.
- **Step-by-step cues** — Simple, graduated prompts that break complex tasks into manageable components to support initiation and sequencing.
- **Therapeutic communication** — Nurse-client interaction that is supportive, nonjudgmental, and preserves autonomy and dignity.
- **Self-care deficit** — Inability to independently perform activities of daily living such as bathing, dressing, and grooming.

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