A nurse overhears a client who has schizophrenia talking to herself. The client keeps stating "The muxtranks are coming. The muntranks are coming. The nurse correctly recognizes the client's use of the word mazuka as an example of which of the following alterations in speech?

Neologism

Clang association

Echolalla

Word salad

Answer and Explanation

The Correct Answer is A

A. Neologism.
Neologism is a language disturbance in which the individual creates new, idiosyncratic words that have meaning only to the individual. In this case, the client's use of "mazuka" is an example of a neologism as it is a made-up word that holds significance only for the client.

B. Clang association involves the association of words based on sound rather than meaning.

C. Echolalia is the repetition of words or phrases spoken by others.

D. Word salad refers to a jumble of words and phrases that lack coherent meaning or logical connection.

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Correct Answer is ["A","B","D"]

Explanation

A. Sodium level: Correct. Sodium imbalances can have serious consequences, including neurological symptoms. Hyponatremia is a common electrolyte imbalance seen in anorexia nervosa.

B. Blood pressure: Correct. Abnormal blood pressure, especially low blood pressure, can indicate cardiovascular compromise, which is a concern in severe cases of anorexia nervosa.

C. Respiratory rate: Not selected. While monitoring respiratory rate is important, the client's pallor and capillary refill suggest potential issues with peripheral perfusion, making capillary refill more urgent.

D. Capillary refill: Correct. Prolonged capillary refill time is a measure of peripheral perfusion and may indicate poor tissue perfusion, requiring immediate attention.

E. Glucose level: Not selected. While monitoring glucose levels is important, hypoglycemia might not be an immediate concern in this scenario. The client's neurological symptoms may be more related to electrolyte imbalances.

F. Phosphate level: Not selected. Monitoring phosphate levels is important, but severe abnormalities may not require immediate follow-up unless other critical issues are addressed first.

G. Magnesium level: Not selected. Magnesium imbalances are significant but may not require immediate follow-up unless severe abnormalities are noted.

A. Check the bruises at the next visit to the client's home. B. Follow the agency's guidelines for reporting suspected abuse. C. Institute more frequent visits to the client's home. D. Arrange referral for family therapy to deal with home stressors.

Correct Answer is B

Explanation

A. Checking the bruises at the next visit may delay necessary intervention. If abuse is suspected, immediate action, such as reporting, is essential to protect the client.

B. Following the agency's guidelines for reporting suspected abuse is the priority when abuse is suspected. Reporting abuse to the appropriate authorities, such as adult protective services or law enforcement, is crucial to ensure the safety and well-being of the older adult.

C. Instituting more frequent visits to the client's home might be part of a safety plan, but it should not be the first action. Reporting suspected abuse is the priority to involve the appropriate authorities.

D. Arranging a referral for family therapy is not the first step in suspected elder abuse. Safety and protection of the older adult take precedence. Once the immediate safety concerns are addressed, additional interventions, such as family therapy, may be considered.

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A nurse overhears a client who has schizophrenia talking to herself. The client keeps stating "The muxtranks are coming. The muntranks are coming. The nurse correctly recognizes the client's use of the word mazuka as an example of which of the following alterations in speech?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","D"]

Explanation

Correct Answer is B

Explanation

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