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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse should not include the client's frequency of call button use in the change-of-shift report. While this information might seem relevant, it can be misinterpreted and stigmatize the client. Sharing call button frequency without context could lead assumptions about the client being overly demanding or attention-seeking, instead of focusing on their potential needs and anxieties post-surgery.
Here's why the other options are acceptable to include:
- a. The last time the provider evaluated the client:This information helps the receiving nurse stay updated on the client's clinical status and recent provider recommendations.
- b. The client's most recent ventilator settings:Although the client is weaned, knowing their past ventilator settings provides valuable insight into their respiratory function and potential risks for decompensation.
- c. The time of the client's last dose of pain medication:This helps manage the client's pain effectively and prevent potential withdrawal symptoms.
Therefore, the best answer is d. The frequency in which the client presses the call button.
Remember, a good change-of-shift report focuses on crucial clinical information relevant to the client's current condition and care plan, avoiding subjective observations that could lead to bias or misjudgment.
Correct Answer is D
Explanation
Choice A rationale:
Insomnia is a common side effect of sertraline and many other antidepressant medications. It is not indicative of serotonin syndrome, a potentially life-threatening condition characterized by excessive serotonin levels in the brain.
Choice B rationale:
Constipation is a side effect of some antidepressant medications, including sertraline. It is not a symptom of serotonin syndrome, which presents with a combination of symptoms such as confusion, agitation, rapid heart rate, dilated pupils, muscle rigidity, and high body temperature.
Choice C rationale:
Dry mouth is another common side effect of sertraline and many other medications. While uncomfortable, it is not a sign of serotonin syndrome. Symptoms of serotonin syndrome are neurological and autonomic, involving changes in mental status, muscle activity, and vital signs.
Choice D rationale:
Excessive sweating, also known as diaphoresis, can be a symptom of serotonin syndrome. Other symptoms might include agitation, tremor, hyperreflexia, fever, dilated pupils, and diarrhea. If a patient experiences these symptoms while taking sertraline, it could indicate serotonin syndrome and should be reported immediately for medical evaluation.
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