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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale: Asking in a non-threatening manner why the client cut their own abdomen is an appropriate therapeutic communication technique but may not be the priority during a dressing change. Safety and hygiene are essential.

Choice B rationale: Providing detailed thorough explanations when cleansing the wound is valuable, but the nurse should prioritize the physical care and safety aspects of the dressing change.

Choice C rationale: Requesting another staff member to assist with the dressing change may be appropriate for some clients, but it may not be necessary for every situation. The nurse should be capable of performing the dressing change safely. Choice D rationale: Performing the dressing change in a non-judgmental manner is crucial. The nurse should focus on providing care in a sensitive and non-critical way to establish trust and ensure the client's physical well-being.

A. Individual addiction counseling. B. Initiate disulfiram teaching. C. Thiamine administration. D. Nutrition referral.

Correct Answer is C

Explanation

Choice A rationale: Individual addiction counseling may be beneficial for the client but does not address the immediate physiological issue of Wernicke encephalopathy. Thiamine replacement is the priority.

Choice B rationale: Initiating disulfiram teaching is not relevant to the management of Wernicke encephalopathy. Disulfiram is used for alcohol aversion therapy, not thiamine deficiency.

Choice C rationale: Thiamine administration is the most critical intervention for Wernicke encephalopathy caused by alcohol addiction. Thiamine deficiency is a key factor in the development of this condition.

Choice D rationale: Nutrition referral may be important for the client's overall well being, but it is not the priority when the client is experiencing Wernicke encephalopathy. Immediate thiamine replacement is essential.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing care for a client diagnosed with a borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the nurse use when changing this client's dressings?

Correct Answer is D

Explanation

A client who experiences memory loss is diagnosed with Wernicke encephalopathy caused by alcohol addiction. Which intervention is most important for the nurse to implement?

Correct Answer is C

Explanation

The healthcare provider prescribes lithium carbonate for a client diagnosed with bipolar, manic depression. It is most important for the nurse to review which laboratory finding prior to beginning the drug therapy?

A client with opioid dependence makes a statement to the nurse about desiring to lead a healthier lifestyle by making changes in the next 2 weeks. How should the nurse respond?

An 18-year-old client is brought to the emergency department with a suspected drug overdose. Which information is most important for the nurse to obtain from the family?

The nurse is preparing a client for discharge who has been taking alprazolam long-term for generalized anxiety disorder (GAD). When evaluating the client's grasp of the discharge teaching, which statement made by the client shows an understanding of the most important self-care goal?

The nurse is planning the care for a client who is hospitalized with a bipolar disorder. The client wanders the hallways, talks excessively, and makes sexual comments about the staff. Which intervention(s) should the nurse include in the plan of care? Select all that apply.

The nurse interacts with a client who is very depressed and slow to respond to questions. The nurse asks the client to describe current feelings, but the client looks down at the table. Which action is best for the nurse to implement?

The occupational health nurse is working with an employee who was just notified that their child was involved in a motor vehicle collision and taken to the hospital. The employee states, "I can't believe this. What should I do?" Which response is best for the nurse to provide in this crisis?

The nurse is providing teaching to a client and family about schizophrenia before discharge from an inpatient facility. The nurse should instruct the family to notify the healthcare provider when which behavior is observed?