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
Choice A rationale: "I know that bathing helps prevent infectious diseases" is a factual statement but may not necessarily reflect progress in the client's overall functioning and engagement in self-care. It focuses on the practical aspect of bathing rather than the client's motivation and insight.
Choice B rationale: "Others say I am dirty and smell badly, so I will bathe" suggests an external motivation rather than intrinsic motivation. Progress is better indicated when the client expresses a personal desire to engage in self-care activities.
Choice C rationale: "I will take a bath today as requested" indicates compliance with external requests rather than an internal desire to care for oneself. It is essential to foster the client's intrinsic motivation for self-care.
Choice D rationale: "I feel good when I take care of myself" reflects an internal motivation and positive reinforcement associated with self-care. This statementsuggests progress in the client's willingness to engage in personal hygiene activities.
Correct Answer is B
Explanation
Choice A rationale: Asking the client about recent substance use is essential in assessing potential intoxication or withdrawal, which could contribute to the client's confused state. However, performing a mental status exam is the most important action to take.
Choice B rationale: The most important action for the nurse to take is to perform a mental status exam. This will help the nurse to assess the client's level of consciousness, orientation, memory, attention, mood, affect, thought process, and judgment. The mental status exam will also help the nurse to identify any signs of psychosis, delirium, dementia, or other mental disorders that may explain the client's behavior. Choice C rationale: Assessing the client from head-to-toe is a general nursing action but does not address the immediate need related to potential substance use. Choice D rationale: Determining the number of previous hospitalizations is relevant but does not address the current concern of substance use contributing to confusion.
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