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?

Neologisms.

Echolalia.

Word salad.

Clang associations.

Answer and Explanation

The Correct Answer is C

Choice C rationale:

The client's speech, "Tie a bow. Row the boat. Now I know. Whoa! I see you, yo," is an example of word salad. Word salad is a disorganized mixture of words and phrases that lack coherent meaning and logical connection. It is often observed in severe cases of schizophrenia or other mental health disorders and indicates a significant impairment in thought process and communication. In word salad, words and phrases are randomly juxtaposed, making it difficult to understand the intended message.

Choice A rationale:

Neologisms are newly coined words or phrases that have meaning only to the individual using them. Neologisms are often created by individuals with mental disorders and might not make sense to others. In the given speech, the words and phrases, although disorganized, are not newly coined or invented terms, so neologisms do not apply here. **

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

February 15.

A. February 1 is not the correct EDB according to Nägele's rule. Nägele's rule states that to estimate the EDB, subtract three months from the LMP and add seven days and one year. Therefore, May 8 minus three months is February 8, plus seven days is February 15, plus one year is February 15 of the following year.
B. February 8 is not the correct EDB according to Nägele's rule. Nägele's rule states that to estimate the EDB, subtract three months from the LMP and add seven days and one year. Therefore, May 8 minus three months is February 8, plus seven days is February 15, minus seven days is February 8, plus one year is February 8 of the following year.
C. February 15 is the correct EDB according to Nägele's rule. Nägele's rule states that to estimate the EDB, subtract three months from the LMP and add seven days and one year. Therefore, May 8 minus three months is February 8, plus seven days is February 15, plus one year is February 15 of the following year.
D. February 22 is not the correct EDB according to Nägele's rule. Nägele's rule states that to estimate the EDB, subtract three months from the LMP and add seven days and one year. Therefore, May 8 minus three months is February 8, plus seven days is February 15, plus seven days is February 22, plus one year is February 22 of the following year.

A. Measure the amount of time the child can hear the sound. B. Obtain a tympanogram reading prior to initiating the test. C. Place a vibrating tuning fork on the top of the child's head. D. Hold a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears.

Correct Answer is C

Explanation

Choice A rationale:

Measuring the amount of time the child can hear the sound is not the correct action when performing Weber's test. Weber's test is used to assess hearing acuity and lateralization. In this test, a vibrating tuning fork is placed in the middle of the patient's forehead, and the patient is asked if the sound is heard equally in both ears or if it is louder in one ear. This helps identify whether there is a conductive or sensorineural hearing loss. The duration of hearing the sound is not relevant to this test.

Choice B rationale:

Obtaining a tympanogram reading is not necessary before initiating Weber's test. Tympanometry assesses the movement of the eardrum in response to changes in air pressure and can help diagnose conditions like middle ear effusion or eustachian tube dysfunction. However, Weber's test focuses on lateralization of sound and does not require tympanogram readings.

Choice C rationale:

Placing a vibrating tuning fork on the top of the child's head is the correct action for performing Weber's test. By doing so, the nurse can assess whether the sound is perceived equally in both ears or if it is lateralized to one ear. If the sound is lateralized, it can provide valuable information about the type of hearing loss the child may have, whether it's conductive or sensorineural.

Choice D rationale:

Holding a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears is not the correct technique for Weber's test. Placing the tuning fork directly on the patient's forehead is essential for accurate assessment. Holding it close to the ears can lead to misinterpretation of the test results.

View Question and Answer

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

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 performing an admission assessment on a client who had a recent positive pregnancy test. The first day of her last menstrual period (LMP) was May 8. According to Nägele's rule, which of the following dates should the nurse document as the client's estimated date of birth (EDB)?

Correct Answer is C

Explanation

A school nurse is using the Weber's test to check a child's hearing acuity.Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is providing dietary teaching to the guardian of a preschooler who has celiac disease.Which of the following foods should the nurse recommend including in the preschooler's diet?

A nurse is caring for a client who has a magnesium level of 2.7 mEq/L. Which of the following interventions should the nurse plan to take?

A nurse is teaching about how to suppress lactation with a client who is postpartum and bottle-feeding her newborn. Which of the following instructions should the nurse include in the teaching?

A nurse is planning care for a client who is undergoing brachytherapy with a low-dose radiation implant for treatment of prostate cancer. Which of the following interventions should the nurse include in the client's plan of care?

A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures should the nurse follow to ensure proper client identification?

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?