A nurse in an acute care facility is assessing a client who has schizophrenia. The client states, "Walk tall broom short dog bell." The nurse should document the client's speech as which of the following speech patterns?

Flight of ideas.

Word salad.

Neologisms.

Clang associations.

Answer and Explanation

The Correct Answer is B

A reason: Flight of ideas. Flight of ideas is characterized by rapid shifts from one topic to another, often with a logical connection between the topics. The client's statement does not exhibit this pattern and is more disorganized.

B reason: Word salad. Word salad refers to a jumble of words and phrases that are incoherent and lack meaningful connections. The client's statement, "Walk tall broom short dog bell," fits this description, as it is a nonsensical combination of words.

C reason: Neologisms. Neologisms are newly created words that have meaning only to the person who uses them. The client's statement does not include any new or invented words, making this choice inappropriate.

D reason: Clang associations. Clang associations involve the use of words based on their sound rather than their meaning, often rhyming or having a similar beginning sound. The client's statement does not exhibit this pattern.

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Correct Answer is B

Explanation

A reason: Keep the client hospitalized until there is no longer a threat. The nurse does not have the authority to independently keep the client hospitalized based on the threat. This decision involves a multidisciplinary approach and, if necessary, legal intervention.

B reason: Ensure the client's ex-partner is notified of the threat. The nurse has a legal and ethical duty to warn individuals who are at risk of harm. Ensuring the ex-partner is notified of the threat is an essential step to protect them from potential danger.

C reason: Ask a friend or family member to monitor the client. While involving friends or family in the client's care is important, it is not the primary legal duty in this situation. Professional intervention and appropriate authorities should be notified.

D reason: Transfer the client to a mental health facility. Transferring the client to a mental health facility may be necessary for their safety and well-being, but the immediate legal duty is to ensure the threatened individual is informed and protected.

A. Cognitive reframing. B. Thought stopping. C. Validation therapy. D. Operant conditioning.

Correct Answer is C

Explanation

A reason: Cognitive reframing. Cognitive reframing involves changing the way a person thinks about a situation to reduce stress or anxiety. While useful in some cases, it is not the most appropriate technique for addressing delusions in clients with dementia.

B reason: Thought stopping. Thought stopping is a technique used to interrupt and control intrusive thoughts, often used in cognitive-behavioral therapy. It is not suitable for managing the delusions of a client with dementia.

C reason: Validation therapy. Validation therapy involves accepting the client's perception of reality and responding in a way that acknowledges their feelings and experiences. For a client with dementia who believes a doll is their infant child, validation therapy helps provide comfort and reduces distress by not challenging their beliefs.

D reason: Operant conditioning. Operant conditioning involves using reinforcement to encourage desired behaviors and discourage undesired ones. It is not appropriate for addressing the delusions of a client with dementia, as it does not validate their experiences.

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A nurse in an acute care facility is assessing a client who has schizophrenia. The client states, "Walk tall broom short dog bell." The nurse should document the client's speech as which of the following speech patterns?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a medical-surgical unit is caring for a client who tells the nurse about their intentions to harm an ex-partner. Which of the following actions is a legal duty of the nurse?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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