A charge nurse is supervising a newly licensed nurse who is caring for a client who is experiencing auditory hallucinations and is refusing medication. The newly licensed nurse suggests placing the medication in the client's food to the charge nurse. Which of the following actions should the charge nurse take?

Suggest the family persuade the client to take the medication.

Recommend that the medication be delivered intramuscularly.

Remind the newly licensed nurse that the client has a right to refuse medication.

Suggest the newly licensed nurse contact the pharmacy to inquire about compatible foods.

Answer and Explanation

The Correct Answer is C

The charge nurse should remind the newly licensed nurse that the client has a right to refuse medication. It is important for healthcare providers to respect the autonomy and rights of their clients, including the right to refuse treatment.

Option a is incorrect because it may not be appropriate for the family to persuade the client to take medication against their wishes.

Option b is incorrect because delivering medication intramuscularly against the client's wishes would violate their right to refuse treatment.

Option d is incorrect because inquiring about compatible foods with the pharmacy would not address the issue of the client's right to refuse medication.

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Correct Answer is C

Explanation

Echolalia is the repetition of words or phrases spoken by others. In this case, the client is repeating the nurse's question, "How are you?" This is an example of echolalia.

a) "I am lovistrated" is an example of neologism, which is the creation of new words.

b) "Super, trooper, and duper" is an example of clang association, which is the use of words that sound alike but have no logical connection.

d) "Pink spots in Africa" is an example of a thought disorder, which is a disruption in the organization and expression of thoughts.

A. The client's foot feels cooler than in the previous assessment. B. The client's pedal pulse in the right foot is not palpable. C. The client's capillary refill time is 5 seconds in the toes. D. The client reports a pain level of 8 on a scale from 0 to 10.

Correct Answer is B

Explanation

The most concerning finding in the assessment of a client's right leg after a femoropopliteal bypass graft would be if the client's pedal pulse in the right foot is not palpable. This could indicate a problem with blood ﬂow to the limb.

The other options are also concerning and should be reported to the healthcare provider.

a) A cooler footmay indicate decreased blood ﬂow to the limb.

c) A capillary refill time of 5 secondsmay also indicate decreased blood ﬂow.

d) A pain level of 8 on a scale from 0 to 10should also be reported and addressed.

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Naxlex Comprehensive Predictor Exams

A nurse in a mental health unit asks a client who has schizophrenia, "How are you?" Which of the following responses should the nurse identify as the speech alteration of echolalia?

Correct Answer is C

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Correct Answer is B

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