Nokea
A client with schizophrenia states to the nurse, 'I am a spy for the FBI. I am an eye, an eye in the sky.' Based on this information, the nurse knows that the client is exhibiting which abnormal thought process?
- A. Echolalia
- B. Word salad
- C. Clang associations
- D. Loosened associations
Correct Answer: C
Rationale: The repetition of words or phrases that are similar in sound and in no other way (rhyming) is one altered thought and language pattern seen in clients with schizophrenia. Clang associations often take the form of rhyming. Echolalia is the involuntary parrot-like repetition of words spoken by others. Word salad is the use of words with no apparent meaning attached to them or to their relationship to one another. Loosened associations occur when the individual speaks with frequent changes of subject and when the content is only obliquely related.
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The nurse on the cardiac unit notes that a client recovering from a myocardial infarction appears worried and irritable. The client says, 'I am worried about my business. I run a restaurant and am used to working 70 hours a week. I am worried about whether I will be able to handle the stress once I am back there.' Which response by the nurse is best?
- A. Give the client a list of complementary therapies related to relaxation and say, 'Pretend this is a menu. Which of these would you like to order for yourself?'
- B. You might find it interesting to attend the cardiac cooking class the dietitian gives before you are discharged.
- C. Who is supposed to be taking care of the restaurant while you are here in the hospital?
- D. Hand the client the television control and say, 'Sometimes when I have a lot on my mind, I watch a movie. It makes me feel better.'
Correct Answer: A
Rationale: Providing a list of relaxation therapies directly addresses the client’s stress concerns and empowers them to choose coping strategies, aligning with their expressed worries about returning to a high-stress job. Other options are less relevant to stress management.
A client who is in halo traction states to the visiting nurse, 'I can't get used to this contraption. I can't see properly on the side, and I keep misjudging where everything is.' Which therapeutic response should the nurse make to the client?
- A. If I were you, I would have had the surgery rather than suffer like this.
- B. No one ever gets used to that thing! It's horrible. Many of our sports people who are in it complain vigorously.
- C. Halo traction involves many difficult adjustments. Practice scanning with your eyes after standing up and before you move around.
- D. Why do you feel like this when you could have died from a broken neck? This is the way it is for several months. You need to be more accepting, don't you think?
Correct Answer: C
Rationale: In option 3, the nurse employs empathy and reflection. The nurse then offers a strategy for problem-solving, which helps increase the peripheral vision of the client in halo traction. In option 1, the nurse undermines the client's faith in the medical treatment being employed by giving advice that is insensitive and unprofessional. In option 2, the nurse provides a social response that contains emotionally charged language that could increase the client's anxiety. In option 4, the nurse uses excessive questioning and gives advice, which is nontherapeutic.
When performing an assessment on a client who is suicidal, which question is the most appropriate for the nurse to ask?
- A. Do you have a death wish?'
- B. Do you wish your life was over?'
- C. Do you ever think about ending it all?'
- D. Do you have any thoughts of killing yourself?'
Correct Answer: D
Rationale: A lethality assessment requires direct communication between the client and the nurse concerning the client's intent. It is important to provide a question that is directly related to lethality. Euphemisms should be avoided.
A client with a new diagnosis of type 1 diabetes mellitus has been seen for 3 consecutive days in the emergency department with hyperglycemia. During the assessment, the client states to the nurse, 'I'm sorry to keep bothering you every day, but I just can't give myself those awful shots.' Which therapeutic comment is most appropriate for the nurse to respond?
- A. I couldn't give myself a shot either.
- B. You must learn to give yourself the shots.
- C. Let me see if we can change your medication.
- D. Have you had instructions on injecting yourself?
Correct Answer: D
Rationale: It is important to determine and deal with a client's underlying fear of self-injection. The nurse should determine whether a knowledge deficit exists. Positive reinforcement should occur rather than focusing on negative behaviors. Demanding that the client perform a behavior or skill is inappropriate. The nurse should not offer a change in regimen that cannot be accomplished.
The nurse provides care for a client diagnosed with a conversion reaction. Which assessment finding does the nurse expect to observe?
- A. The client is experiencing delusions of messianic grandeur.
- B. The client believes that the world is ending on a specific date.
- C. The client is experiencing persistent pain after the resolution of herpes zoster.
- D. The client is experiencing blindness without an identified physical cause.
Correct Answer: D
Rationale: Conversion disorder involves physical symptoms, like blindness, without a medical cause, often linked to psychological stress. Blindness without a physical cause is a classic example, unlike delusions or unrelated pain.