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A nurse is caring for a client who states during a counseling session, "I am sliding off a cliff." Which of the following statements should the nurse make?

"I don't think that is really what is happening to you."

"Don't worry. Everything will be okay."

"How are things going at your job?"

"You must be feeling very frightened right now."

Answer and Explanation

The Correct Answer is D

A. This statement dismisses the client's feelings.

B. Offering false reassurance is not therapeutic.

C. Changing the subject does not address the client's distress.

D. This is the correct answer. Acknowledging the client's feelings is a therapeutic response that encourages further discussion.

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Correct Answer is C

Explanation

A. Echolalia refers to the repetition of words spoken by another person.

B. Word salad is a mix of random, unrelated words with no logical connection.

C. This is the correct answer. Clang association involves rhyming words that are spoken together without meaningful connections, as seen in the client's statement.

D. Neologisms are made-up words that have meaning only to the individual.

A. Watery stool B. Oliguria C. Dizziness D. Abdominal distention

Correct Answer is D

Explanation

A. Watery stool is not a typical sign of paralytic ileus; instead, bowel sounds are absent or hypoactive.

B. Oliguria (low urine output) is not directly related to paralytic ileus.

C. Dizziness is not a primary symptom of paralytic ileus.

D. This is the correct answer. Abdominal distention occurs due to the accumulation of gas and fluid in the intestines, which are unable to move due to ileus.

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A nurse is caring for a client who states during a counseling session, "I am sliding off a cliff." Which of the following statements should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

A nurse is assessing a client who is postoperative following orthopedic surgery. Which of the following findings should the nurse identify as an indication of paralytic ileus?

Correct Answer is D

Explanation

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