A client on an acute mental health unit states to a nurse. "Tie a bow. Row the boat. Now I know. Whoa! I see you, yo." The nurse should document that the client is exhibiting which of the following speech alterations?

Echolalia

Word salad

Clang association

Neologisms

Answer and Explanation

The Correct Answer is C

A. Echolalia refers to the repetition of words spoken by another person.

B. Word salad is a mix of random, unrelated words with no logical connection.

C. This is the correct answer. Clang association involves rhyming words that are spoken together without meaningful connections, as seen in the client's statement.

D. Neologisms are made-up words that have meaning only to the individual.

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Correct Answer is C

Explanation

A. Healthy weight – A BMI between 18.5 and 24.9 is classified as healthy. Since the client's BMI is 17.2, they do not fall within this range.

B. Overweight – Overweight is defined as a BMI between 25.0 and 29.9. The client's BMI of 17.2 is far below this range.

C. Underweight – A BMI below 18.5 is classified as underweight. Since the client's BMI is 17.2, they fall into this category. Clients with Crohn’s disease often experience malabsorption and weight loss, leading to a low BMI.

D. Obesity class 1 – Obesity is categorized as a BMI of 30.0 or higher. The client’s BMI is far below this classification.

A. Call the nurse who made the error to discuss the medication error. B. File an incident report within 24 hr. C. Notify the facility's pharmacist within 1 hr of the incident. D. Place an incident report in the client's medical record.

Correct Answer is B

Explanation

Rationale:

A. Call the nurse who made the error to discuss the medication error – This is not the appropriate action. The focus should be on client safety and proper reporting, not on discussing the error with the previous nurse.

B. File an incident report within 24 hr – This is the correct action. Incident reports should be completed promptly to document the error and ensure proper follow-up.

C. Notify the facility's pharmacist within 1 hr of the incident – While the pharmacist may be informed if a medication reversal or adjustment is needed, this is not the primary action to take.

D. Place an incident report in the client’s medical record – Incident reports are internal documents and should not be placed in the medical record to avoid legal concerns.

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A client on an acute mental health unit states to a nurse. "Tie a bow. Row the boat. Now I know. Whoa! I see you, yo." The nurse should document that the client is exhibiting which of the following speech alterations?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has Crohn's disease. The nurse calculates that the client's BMI is 17.2. The nurse should document the client's weight status as being within which of the following categories?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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