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
MDMA, commonly known as ecstasy or Molly, is a stimulant drug that affects the central nervous system. It primarily acts on serotonin, dopamine, and norepinephrine neurotransmitters. The use of MDMA can lead to altered perception, increased sensory awareness, and hallucinations. Hallucinations may involve visual, auditory, or tactile sensations that are not based on reality.
The other findings mentioned—hypothermia (abnormally low body temperature), somnolence (excessive sleepiness), and muscle weakness—are not typically associated with MDMA use. Instead, MDMA use may lead to increased body temperature (hyperthermia), increased energy levels, agitation, increased heart rate, and muscle tension.
Correct Answer is D
Explanation
The first action the nurse should take is to reevaluate the client's response to the medication in 30 min. Hydromorphone has an onset of action of 15 to 30 minutes when taken orally ¹. Therefore, it may take some time for the medication to reach its full effect.
Option a is incorrect because it may not be necessary to contact the provider for more pain medication until after reevaluating the client's response to the medication.
Option b is incorrect because teaching relaxation techniques may not provide immediate relief for acute pain.
Option c is incorrect because documenting the client's reaction to the administration of medication should be done after reevaluating their response to the medication.
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