Nokea
The nurse is caring for a client with a history of schizophrenia. The nurse asks the client if he is ready to eat his lunch. The client responds, 'Rain, train, down the drain, Jane's brain.' The nurse recognizes this type of speech pattern as which type?
- A. echolalia
- B. word salad
- C. neologisms
- D. clang association
Correct Answer: D
Rationale: Clang association is characterized by words chosen for their sound (e.g., rhyming or alliteration) rather than meaning, as seen in the client's response.
You may also like to solve these questions
The nurse provides care for a client diagnosed with substance abuse. The nurse recognizes the client is using projection as a defense mechanism when the client makes which statement?
- A. There is genetic predisposition in my family to alcoholism.
- B. My spouse takes handfuls of medications, and I don't do that.
- C. I have one or two glasses of wine at dinner with my spouse.
- D. Many psychologists do not believe addiction is a disease.
Correct Answer: B
Rationale: Projection involves attributing one's own undesirable behaviors to others. The client blaming their spouse for excessive medication use reflects projection by deflecting their own substance abuse issues onto another person.
A client who has a history of depression has been prescribed nadolol for the management of angina pectoris. Which consideration is most important when the nurse plans to counsel this client about the effects of this medication?
- A. Risk of tachycardia
- B. Probability of fatigue
- C. High incidence of hypoglycemia
- D. Possible exacerbation of depression
Correct Answer: D
Rationale: Clients with depression or a history of depression have experienced an exacerbation of depression after beginning therapy with beta-adrenergic blocking agents. These clients should be monitored carefully if these agents are prescribed. The medication would cause bradycardia rather than tachycardia. Fatigue is a possible side effect, but it is not the most important item. Hypoglycemia is a sign that is masked with beta blockers.
A nurse in the outpatient clinic receives four phone messages. Which call does the nurse return first?
- A. The parent of a preschool-age child who continuously throws temper tantrums, is always moving, and is impulsive.
- B. The parent whose adolescent child has vomited every day for 2 weeks and now weighs 74 pounds.
- C. The parent who receives calls from the school about an adolescent child's aggressive behavior toward schoolmates.
- D. The adult child of an older adult who is having difficulty sleeping after a spouse died 2 weeks ago.
Correct Answer: B
Rationale: An adolescent vomiting daily for 2 weeks and weighing 74 pounds indicates a critical health issue, likely severe dehydration or malnutrition, requiring urgent assessment to prevent life-threatening complications. This takes priority over behavioral, aggression, or grief-related concerns.
The nurse is caring for a client who has been admitted to the hospital for the insertion of a subclavian central venous catheter (CVC). The client is concerned because her job requires that she frequently works with the public. With this assessment data, which client concern would be the priority when managing care?
- A. Poor self-care
- B. Body image insecurity
- C. Neck range of motion restrictions
- D. Uncontrolled pain related to the CVC
Correct Answer: B
Rationale: Psychosocial assessment includes client data related to psychological and social issues. The CVC can create socially awkward situations and impair the client's security in her body image. The client data presented do not support assessing the client for poor self-care. Although pain and neck range of motion are valid issues for this client, options 3 and 4 are physiological issues and do not relate to the concerns of the client.
A client with a history of pulmonary emboli is scheduled for the insertion of an inferior vena cava filter. The nurse checks on the client 1 hour after the primary health care provider has explained the procedure and obtained informed consent from the client. The client is lying in bed, wringing his hands, and states to the nurse, 'I'm not sure about this. What if it doesn't work and I'm just as bad off as before?' Which concern for the client should the nurse identify at this time?
- A. Anxiety and depression
- B. Inability to handle the treatment regimen
- C. Lack of knowledge about the surgical procedure
- D. Fear about the potential risks and outcomes of surgery
Correct Answer: D
Rationale: This client has indicated the surgical procedure and its outcome as the object of fear. Anxiety is present when the client cannot identify the source of the uneasy feelings. Presently there are not indications that the client is depressed. A client's inability to handle a treatment regimen would be when the client is not making needed adaptations to deal with daily life. Lack of knowledge would be when there is a lack of appropriate information.