During the initial nursing interview, a client tells the nurse, "Sometimes my thoughts go so fast. Wonder if I can sell my fast car. Work is so boring. I wonder if I can get a transfer. Is it time to eat yet?" Which documentation should the nurse enter in the electronic medical record to describe the client's statements?
Demonstrates thought-blocking.
Exhibits tangential thinking.
Displays the use of word salad.
Uses incoherent speech.
The Correct Answer is B
Choice A rationale: Demonstrates thought-blocking is incorrect. Thought-blocking involves a sudden interruption in the client's speech, whereas the client in this scenario is experiencing racing thoughts.
Choice B rationale: Exhibits tangential thinking is the correct description. Tangential thinking involves presenting numerous ideas that are loosely or not at all connected. The client's statements reflect tangential thinking as she jumps from one idea to another without clear connections.
Choice C rationale: Displays the use of word salad is incorrect. Word salad refers to a mix of words and phrases that lack coherence and do not form a meaningful statement. The client's statements, though rapid, are connected and form a series of thoughts. Choice D rationale: Uses incoherent speech is incorrect. Incoherent speech implies a lack of clarity and organization in the client's verbal expression. The client's statements, while fast-paced, maintain coherence and are comprehensible.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. An overdose of cocaine can be lethal:
While this statement is accurate, it focuses on extreme outcomes rather than addressing the student's belief in their ability to control cocaine use. It may not encourage the student to reconsider their stance on trying the drug.
B. Addiction affects all aspects of one's life and one's family:
This response provides important information about the long-term consequences of addiction but does not directly counter the student's claim about their ability to control initial use. It may not be as impactful in the immediate context.
C. Denial of an addiction problem is often the first response to the behavior:
This response assumes the student is already using substances or experiencing addiction. It does not directly address the student's specific belief in their ability to control their actions after trying cocaine.
D. Mind-altering drugs take away one's ability to make good decisions:
This response is most appropriate because it directly challenges the student's confidence in their ability to control their behavior. It provides a logical explanation of why experimenting with cocaine is inherently risky, as it impairs judgment and decision-making, making it harder to "stop" as they claim
Correct Answer is B
Explanation
Choice A rationale: Monitoring for binging activities is important, but addressing the potential physiological complications of bulimia, such as electrolyte imbalances, takes precedence.
Choice B rationale: Assessing and reporting the client's electrolyte status is the highest priority as bulimia nervosa can lead to severe electrolyte imbalances, which may result in life-threatening complications.
Choice C rationale: Assigning care based on age is not a priority in addressing the immediate health risks associated with bulimia nervosa.
Choice D rationale: While group therapy is beneficial, addressing the client's physical health and safety is the highest priority.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today