The client is describing her trip to town. She tells the nurse, 'I cold town yellow water girl outside below ground.' This speech disturbance is called:

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Question 1 of 5

The client is describing her trip to town. She tells the nurse, 'I cold town yellow water girl outside below ground.' This speech disturbance is called:

Correct Answer: B

Rationale: The correct answer is B: Word salad. This speech disturbance is characterized by a jumble of words that lack coherent meaning or connection. In this case, the client's words are disorganized and nonsensical. Neologism (A) is the creation of new words, not a jumble of existing words. Flight of ideas (C) involves rapid shifts in thoughts without a clear connection, not a jumble of words. Verbigeration (D) is the constant repetition of words or phrases, not a jumble of unrelated words.

Question 2 of 5

A patient who has been physically abused says, 'When I called the police, I just wanted my spouse to stop shoving me around and kicking me. I didn't want anyone to get in trouble. It's easy to get angry with me because I spend too much money.' Which nursing intervention would be most therapeutic for this patient?

Correct Answer: A

Rationale: The correct answer is A because it focuses on therapeutic communication by reflecting the patient's feelings and thoughts back to them without judgment. By repeating the patient's words, the nurse shows empathy and understanding, which can help build trust and rapport. Choices B and D may escalate the situation and go against the patient's wishes, potentially causing further harm. Choice C assumes a causal relationship between overspending and abuse, which is not appropriate and may blame the victim. Overall, choice A promotes a non-judgmental and supportive environment, which is crucial in addressing issues of abuse.

Question 3 of 5

A 45-year-old married woman who works full time in a factory has recently been absent for 3-day periods on several occasions. Each time, she returned to work wearing dark glasses. Facial and body bruises were apparent. Her supervisor became suspicious that she was a victim of battering and referred her to the occupational health nurse. What should the nurse first focus on as she meets the patient?

Correct Answer: C

Rationale: The correct answer is C: Establishing trust and building rapport. The nurse should first focus on building a trusting relationship with the patient to create a safe environment for her to disclose any abuse she may be experiencing. By establishing trust and rapport, the nurse can gain the patient's confidence and encourage her to open up about her situation. This approach is crucial in ensuring the patient feels supported and empowered to seek help. Incorrect choices: A: Notifying the police of the abuse - This may jeopardize the patient's safety and could worsen the situation if she is not ready to involve law enforcement. B: Documenting the woman's injuries - While documenting injuries is important, it should not be the first step as it may further distress the patient without addressing the underlying issue. D: Collecting evidence to prosecute the abuser - Prosecution should not be the initial focus; the priority should be on the patient's well-being and safety.

Question 4 of 5

A mother discusses her concerns about genetic transmission of schizophrenia with the nurse saying, 'My son is a fraternal twin. He has been diagnosed with schizophrenia. Will my other son develop schizophrenia, too?' The response that is both sensitive and shows understanding of the genetic component is:

Correct Answer: D

Rationale: The correct answer is D because it provides an accurate and sensitive response. Fraternal twins do not share the same genetic makeup as identical twins, so the genetic risk for the other twin developing schizophrenia is lower. By acknowledging this fact, the nurse offers reassurance to the mother without giving false hope or inaccurate statistics. This response shows understanding of the genetic component of schizophrenia and addresses the mother's concerns in a compassionate and informative manner. Choices A, B, and C are incorrect: A: This response is dismissive of the mother's concerns and does not provide any helpful information. It also lacks sensitivity and empathy towards the mother's situation. B: This response provides an inaccurate statistic about the likelihood of the other twin developing schizophrenia. It does not consider the difference between identical and fraternal twins, leading to a potentially misleading statement. C: This response is vague and does not address the mother's question directly. It does not provide any useful information or reassurance, leaving the mother uncertain and anxious about

Question 5 of 5

When a patient diagnosed with paranoid schizophrenia was discharged from the unit 6 months ago, the plan was for him to take chlorpromazine (Thorazine), a conventional (first generation) antipsychotic medication, 300 mg po daily. He tells the nurse he stopped taking his pills after a few months because they made him feel like a 'zombie.' What other common side effects should the nurse determine if the patient experienced?

Correct Answer: B

Rationale: The correct answer is B: Sedation, tremor, and muscle stiffness. These side effects are commonly associated with conventional antipsychotic medications like chlorpromazine. Sedation is a common side effect that can make the patient feel drowsy or sluggish. Tremors are involuntary muscle movements that can affect the hands, arms, or legs. Muscle stiffness can cause rigidity and difficulty moving smoothly. These side effects are known to impact the quality of life and may contribute to the patient feeling like a 'zombie.' Choices A, C, and D are incorrect because they do not align with the common side effects of conventional antipsychotic medications. Sweating, nausea, and weight gain (Choice A) are not typical side effects of chlorpromazine. Headache, watery eyes, and runny nose (Choice C) are more commonly associated with allergies or cold symptoms rather than antipsychotic medications. Mild fever, sore throat, and skin rash (Choice D)

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