A client on an acute mental health unit states to a nurse. "Tie a bow. Row the boat. Now I know. Whoa! I see you, yo." The nurse should document that the client is exhibiting which of the following speech alterations?
Echolalia
Word salad
Clang association
Neologisms
The Correct Answer is C
A. Echolalia refers to the repetition of words spoken by another person.
B. Word salad is a mix of random, unrelated words with no logical connection.
C. This is the correct answer. Clang association involves rhyming words that are spoken together without meaningful connections, as seen in the client's statement.
D. Neologisms are made-up words that have meaning only to the individual.
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Related Questions
Correct Answer is D
Explanation
A. Switch to a lactose-free formula – A lactose-free formula is necessary for clients with lactose intolerance but does not address the issue of hyperosmolar dehydration, which results from insufficient free water intake rather than intolerance to lactose.
B. Reposition the NG tube – Repositioning the tube is necessary if there is displacement, but it does not treat dehydration caused by hyperosmolar feedings.
C. Increase the rate of formula delivery – Increasing the rate can worsen dehydration by further increasing the solute load, leading to a greater fluid shift from intracellular to extracellular spaces.
D. Add water to the formula – This is the correct answer because hyperosmolar dehydration occurs when high-solute enteral formulas pull water into the intestines, leading to excessive fluid loss. To prevent this, the nurse should ensure the client receives adequate free water flushes alongside tube feedings.
Correct Answer is A
Explanation
A. This is the correct answer. A snug-fitting bra helps suppress lactation and provides support to relieve discomfort. It should be worn continuously, even while sleeping, for 72 hours.
B. Moist heat stimulates milk production and should be avoided. Instead, cold compresses can help reduce swelling.
C. Fluid restriction is not necessary and could lead to dehydration.
D. Manually expressing milk will encourage continued milk production rather than suppressing lactation.
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