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 A
Explanation
A client statement that indicates an understanding of discharge teaching for type 1 diabetes mellitus is "I will dispose of insulin needles in a puncture-proof container." This is the correct way to dispose of insulin needles to prevent accidental needle sticks.
The other options are not correct.
b) Opened insulin vials do not need to be stored in the refrigerator, but should be kept at room temperature.
c) Insulin vials should not be shakenas this can cause the insulin to break down.
d) Regular insulin should appear clear, not cloudy.
Correct Answer is D
Explanation
The subjective indication that the client needs PRN (as needed) pain medication is when the client reports pain. Pain is a subjective experience, and it is essential to address the client's self-reported pain level and provide appropriate pain management.
Explanation for the other options:
a) The client's heart rate is 110/min: An increased heart rate can be an objective indication of pain, but it is not a subjective indication. Subjective indications are based on the client's self-report or personal experiences.
b) The client is guarding their abdominal incision: Guarding the abdominal incision may suggest discomfort or pain, but it is an objective indication that can be observed by the nurse. Subjective indications focus on the client's self-report.
c) The client exhibits facial grimacing: Facial grimacing can be an objective indication of pain, but it is not a subjective indication. Again, subjective indications are based on the client's self-report or personal experiences.
In this scenario, the most reliable and appropriate indication for administering PRN pain medication is when the client reports pain, as this acknowledges the client's own perception of their pain level.
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