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 C
Explanation
Choice A rationale: Telling the client that irrational thinking is a symptom of schizophrenia may not be well-received and could lead to increased resistance. It is essential to address the immediate concern of food refusal.
Choice B rationale: Assuring the client that all food served in the hospital is safe to eat may not be sufficient, especially if the client has strong delusional beliefs about poisoning. Offering food in unopened containers is a more practical approach. Choice C rationale: Providing the client with food in unopened containers is a reasonable intervention. It addresses the client's concerns about poisoning and ensures that the food is perceived as safe.
Choice D rationale: Obtaining an order for a tube feeding for the client may be considered if the client continues to refuse solid food. However, providing food in unopened containers is an initial step to encourage the client to eat.
Correct Answer is A
Explanation
Choice A rationale: Providing information about available community resources is crucial during the discharge phase to support the client's transition to the community and ongoing care.
Choice B rationale: Exploring the client's feelings related to discharge is important, but providing practical information about available resources is more immediate and can aid in the client's continuity of care.
Choice C rationale: Asking the client to describe alternative coping mechanisms is relevant, but connecting the client with community resources is a more immediate concern during the discharge phase.
Choice D rationale: Discussing potential medication side effects is important, but linking the client to community resources takes precedence during the discharge process.
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