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?
Neologisms.
Echolalia.
Word salad.
Clang associations.
The Correct Answer is C
Choice C rationale:
The client's speech, "Tie a bow. Row the boat. Now I know. Whoa! I see you, yo," is an example of word salad. Word salad is a disorganized mixture of words and phrases that lack coherent meaning and logical connection. It is often observed in severe cases of schizophrenia or other mental health disorders and indicates a significant impairment in thought process and communication. In word salad, words and phrases are randomly juxtaposed, making it difficult to understand the intended message.
Choice A rationale:
Neologisms are newly coined words or phrases that have meaning only to the individual using them. Neologisms are often created by individuals with mental disorders and might not make sense to others. In the given speech, the words and phrases, although disorganized, are not newly coined or invented terms, so neologisms do not apply here. **
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hypoxemia is a condition of low oxygen levels in the blood. PEEP can actually improve oxygenation by preventing alveolar collapse and increasing functional residual capacity.
B. Tension pneumothorax is a life-threatening condition of air accumulation in the pleural space that causes increased intrathoracic pressure and compresses the lungs, heart, and great vessels. PEEP can increase the risk of tension pneumothorax by creating excessive positive pressure in the airways and alveoli.
C. Malignant hypertension is a severe form of high blood pressure that can cause organ damage and stroke. PEEP can cause a transient increase in blood pressure due to increased intrathoracic pressure, but it does not cause malignant hypertension.
D. Atelectasis is a condition of partial or complete lung collapse due to alveolar collapse or obstruction. PEEP can prevent or treat atelectasis by maintaining positive pressure in the airways and alveoli.
Correct Answer is A
Explanation
- A. The nurse should discourage raw fruits due to risk of infection.
- B. There is no standard recommendation against exposure to young children.
- C. Incorrect. The nurse should measure the client's temperature at least every 4 hr, or more frequently if indicated because fever is a sign of infection in a client who has neutropenia and requires prompt intervention.
- D. Incorrect. The nurse should use disposable gloves from a box inside the client's room, not outside, to prevent cross-contamination and protect the client from exposure to pathogens.
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