A nurse in an acute care facility is assessing a client who has schizophrenia. The client states, "Walk tall broom short dog bell." The nurse should document the client's speech as which of the following speech patterns?

Flight of ideas.

Word salad.

Neologisms.

Clang associations.

Answer and Explanation

The Correct Answer is B

A reason: Flight of ideas. Flight of ideas is characterized by rapid shifts from one topic to another, often with a logical connection between the topics. The client's statement does not exhibit this pattern and is more disorganized.

B reason: Word salad. Word salad refers to a jumble of words and phrases that are incoherent and lack meaningful connections. The client's statement, "Walk tall broom short dog bell," fits this description, as it is a nonsensical combination of words.

C reason: Neologisms. Neologisms are newly created words that have meaning only to the person who uses them. The client's statement does not include any new or invented words, making this choice inappropriate.

D reason: Clang associations. Clang associations involve the use of words based on their sound rather than their meaning, often rhyming or having a similar beginning sound. The client's statement does not exhibit this pattern.

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Correct Answer is ["B","C"]

Explanation

A reason: Hallucinations. Hallucinations can be distressing and are associated with various mental health conditions, but they are not a direct indicator of suicide risk without other contributing factors.

B reason: Depression. Depression is a significant risk factor for suicide. Clients experiencing persistent sadness, hopelessness, and a lack of interest in life are at a higher risk for attempting suicide.

C reason: Delusions. Delusions, particularly those that are paranoid or nihilistic, can contribute to feelings of hopelessness and despair, increasing the risk of suicide attempts.

D reason: Catatonia. Catatonia involves motor immobility and behavioral abnormality. While it is a serious condition requiring treatment, it is not a direct indicator of suicide risk without other contributing factors.

E reason: Tinnitus. Tinnitus, or ringing in the ears, is not associated with an increased risk of suicide. It is a physical symptom that does not directly influence suicidal behavior.

A. Administer a sedative medication. B. Perform a debriefing with the staff. C. Acknowledge the client's emotions. D. Place the client in restraints.

Correct Answer is C

Explanation

A reason: Administer a sedative medication. While administering a sedative may be necessary to calm the client, it is not the first step. The nurse should initially attempt to de-escalate the situation using non-pharmacological interventions.

B reason: Perform a debriefing with the staff. Debriefing with the staff is important after the situation is under control, but it is not the immediate priority. The focus should first be on addressing the client's behavior and emotions.

C reason: Acknowledge the client's emotions. Acknowledge the client's emotions to de-escalate the situation and help the client feel heard and understood. This can reduce the immediate risk of violence or self-harm.

D reason: Place the client in restraints. Restraints should be used as a last resort when other interventions have failed and there is an immediate risk of harm. The nurse should first try to calm the client through verbal and emotional support.

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A nurse in an acute care facility is assessing a client who has schizophrenia. The client states, "Walk tall broom short dog bell." The nurse should document the client's speech as which of the following speech patterns?

Nursing Test Bank

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