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?
"I am lovistrated."
"Super, trooper, and duper."
"How are you?"
"Pink spots in Africa."
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
c. Initiate a client referral to Reach to Recovery.
Explanation:
When caring for a female client who has a new diagnosis of breast cancer and expresses concerns about potential changes to her body image, the nurse should initiate a client referral to Reach to Recovery. Reach to Recovery is a program provided by the American Cancer Society that connects breast cancer patients with trained volunteers who have gone through a similar experience. These volunteers can provide emotional support, information, and resources to help the client cope with the physical and emotional changes that may occur due to breast cancer and its treatment.
Explanation for the other options:
a .Reassure the client that she will adjust to changes to her body:
While providing reassurance is important, it may not be sufficient to address the client's concerns about potential changes to her body image. Initiating a referral to Reach to Recovery can provide the client with additional support and resources tailored to her specific needs.
b. Contact an occupational therapist to talk with the client:
While an occupational therapist may have valuable input on certain aspects of the client's care, such as functional abilities and adaptations, initiating a referral to Reach to Recovery would be more appropriate for addressing the client's concerns related to body image.
d. Explain that surgery can restore the breast to its original appearance:
While surgery options such as breast reconstruction can restore the breast to a similar appearance, it is not appropriate for the nurse to make guarantees about the outcome or appearance of the breast after surgery. Every individual's situation is unique, and the decision to undergo surgery and the results of such procedures are dependent on various factors. Referring the client to Reach to Recovery would be more beneficial in addressing her concerns holistically.
In summary, when a client with a new diagnosis of breast cancer expresses concerns about potential changes to her body image, the nurse should initiate a client referral to Reach to Recovery. This program can provide the client with the necessary emotional support and resources to navigate the physical and emotional changes associated with breast cancer and its treatment.
Correct Answer is A
Explanation
The initial diphtheria, tetanus, and pertussis (DTaP) vaccine is indicated for a 2-month-old infant. The DTaP vaccine is typically administered as a series of doses starting in infancy to provide protection against diphtheria, tetanus, and pertussis (whooping cough).
The recommended schedule for the DTaP vaccine includes a series of doses at 2, 4, and 6 months of age, with additional booster doses given later in childhood. Therefore, the first dose of DTaP is given to infants at 2 months of age.
The other options are incorrect because:
b) A 4-month-old infant: By 4 months of age, the second dose of the DTaP vaccine should be administered, not the initial dose.
c) A 6-month-old infant: By 6 months of age, the third dose of the DTaP vaccine should be administered, not the initial dose.
d) A 15-month-old toddler: By 15 months of age, the toddler would have already received multiple doses of the DTaP vaccine as part of the recommended series. The initial dose is typically given earlier, at 2 months of age.
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