During the admission interview for a client with schizophrenia, the nurse asks the client "tell me the names of the medications you are currently taking. The client responds, medications, abbreviations, deviations, mediations." The nurse will document which form of speech pattern the client is demonstrating?

Neologisms

Echolalia

Pressured speech

Clang association

Answer and Explanation

The Correct Answer is D

A. Neologisms refer to made-up words or phrases that have meaning only to the individual. The client's response does not include invented terms but rather consists of real words that are nonsensically grouped.

B. Echolalia is the repetition of words or phrases spoken by others. The client's response does not reflect repetition of the nurse's words but rather a disjointed response of their own.

C. Pressured speech involves rapid and often incoherent speech that reflects a sense of urgency. The client's response lacks the rapid flow characteristic of pressured speech.

D. Clang association is characterized by speech in which the individual connects words based on their sound rather than their meaning. The client's response ("medications, abbreviations, deviations, mediations") demonstrates this pattern, as the words are linked by similar sounds rather than by content or coherent thought.

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Correct Answer is C

Explanation

A. The Michigan Alcohol Screening Test (MAST) is a tool used to screen for alcohol abuse or dependence, but it does not specifically assess withdrawal symptoms.

B. The CAGE questionnaire is used to screen for alcohol abuse, but it does not assess withdrawal symptoms.
C. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) is a validated tool used to assess the severity of alcohol withdrawal symptoms. It includes various criteria such as agitation, tremor, and hallucinations.
D. The Delirium Rating Scale (DMSE) is used to assess the severity of delirium, which can be caused by various factors including alcohol withdrawal, but it is not specific to alcohol withdrawal.

A. Plan to discuss any topic that is presented. B. Focus on client weaknesses to increase adaptation. C. Provide continuity of care by assigning the same staff. D. Allow client to determine the boundaries of the nurse client relationship.

Correct Answer is C

Explanation

A) Incorrect. While discussing various topics is important, providing continuity of care is more crucial in creating a therapeutic environment for clients with paranoia and schizophrenia.

B) Incorrect. Focusing on client strengths rather than weaknesses is generally a more effective approach in mental health care.

C) Correct. Providing continuity of care by assigning the same staff helps build trust and a sense of security for clients, especially those with paranoia and schizophrenia.
D) Incorrect. While it's important to establish boundaries, allowing the client to solely determine them may not always be in their best interest.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While conducting an admission interview with a client, the nurse suspects the client may be in alcohol withdrawal. Which screening tool can help the nurse identify the severity of withdrawal symptoms?

Correct Answer is C

Explanation

A nurse is planning to run a group for clients diagnosed with paranoia and schizophrenia on an acute care mental health unit. Which of the following actions should the nurse plan to take to create a therapeutic environment?

Correct Answer is C

Explanation

A client diagnosed with schizophrenia is experiencing delusions of persecution. How would the client express feeling persecuted?

A client with schizophrenia has begun a new prescription of clozapine. The nurse should assess the result of which laboratory study to monitor for adverse effects?

A nurse is preparing to administer fluoxetine 80 mg PO daily. Available is fluoxetine 40 mg/5mL. How many mL should the nurse administer per dose? (Write the number only, do not include the label. Record the answer to the nearest whole number. Do not use a trailing zero)

A nurse is providing teaching for a client who has schizophrenia and a new prescription for risperidone. Which of the following statements should the nurse include in the teaching?

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A nurse is providing teaching for a client who has schizophrenia and a new prescription for risperidone. Which of the following statements should the nurse include in the teaching?

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