The client hears the word “match.” The client replies, “A match is a catch. A catch is a batch. The batch started to hatch.” Which communication pattern does the nurse identify?
Word salad.
Loose association.
Clang association.
Ideas of reference.
The Correct Answer is C
Choice A Reason:
Word salad.
Word salad refers to a jumble of words and phrases that lack logical coherence, often seen in severe cases of schizophrenia. The speech is typically incomprehensible and does not follow any recognizable pattern. In this case, the client’s response, while unusual, follows a pattern based on sound rather than meaning, which does not fit the definition of word salad.
Choice B Reason:
Loose association.
Loose association involves a series of thoughts that are only loosely connected to each other. This is a common symptom in schizophrenia, where the person’s thoughts may drift from one topic to another with little logical connection. However, the client’s response in this scenario is more structured and based on rhyming, which is characteristic of clang associations rather than loose associations.
Choice C Reason:
Clang association.
Clang association is a type of thought disorder where the person’s speech is governed by the sound of words rather than their meaning. This often results in rhyming or punning speech. The client’s response, “A match is a catch. A catch is a batch. The batch started to hatch,” is a clear example of clang association because the words are linked by their similar sounds rather than their meanings.
Choice D Reason:
Ideas of reference.
Ideas of reference involve the belief that ordinary events, objects, or behaviors of others have particular and unusual significance specifically for the person. This is often seen in paranoid schizophrenia. The client’s response does not indicate that they believe the words have special personal significance; instead, it shows a pattern of rhyming, which is more indicative of clang association.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A Reason:
Use a calm voice.
Using a calm voice is essential in de-escalating an agitated client. A calm and steady tone can help soothe the client and reduce their anxiety. It also demonstrates that the nurse is in control of the situation and is there to help, which can be reassuring for the client.
Choice B Reason:
Speak louder than the client so as to be heard.
Speaking louder than the client is not appropriate as it can escalate the situation further. Raising one’s voice can be perceived as confrontational and may increase the client’s agitation. It is important to maintain a calm and composed demeanor to help de-escalate the situation.
Choice C Reason:
Reduce stimuli for the client.
Reducing stimuli is an effective intervention for an agitated client. Excessive noise, bright lights, and other environmental stimuli can exacerbate agitation. Creating a quieter and more controlled environment can help the client feel more at ease and reduce their agitation.
Choice D Reason:
Attempt to redirect the client.
Attempting to redirect the client can be helpful in de-escalating agitation. Redirecting the client’s attention to a different topic or activity can help distract them from the source of their agitation and provide a sense of control. This technique can be effective in calming the client and preventing further escalation.
Choice E Reason:
Reprimand the client for upsetting everyone.
Reprimanding the client is not an appropriate intervention. It can increase the client’s feelings of frustration and agitation. Instead, the focus should be on understanding the client’s needs and providing support to help them calm down.
Correct Answer is B
Explanation
Choice A Reason:
Increase external stimuli.
Increasing external stimuli is not appropriate during a panic attack. Panic attacks are characterized by intense fear and anxiety, often accompanied by physical symptoms such as rapid heartbeat, sweating, and shortness of breath. Increasing external stimuli can exacerbate these symptoms and heighten the client’s distress. The goal during a panic attack is to reduce stimuli and create a calming environment to help the client regain control.
Choice B Reason:
Stay with the client and speak to them in a calm manner.
This is the correct response. Staying with the client and speaking to them in a calm manner provides reassurance and helps to ground them during the panic attack. The presence of a calm and supportive nurse can help reduce the client’s anxiety and provide a sense of safety. This approach aligns with therapeutic communication techniques and is effective in managing acute anxiety episodes.
Choice C Reason:
Allow the client to have their requested space.
While it is important to respect a client’s need for space, leaving them alone during a panic attack may not be the best approach. Clients experiencing panic attacks may feel overwhelmed and frightened, and the presence of a supportive nurse can help them feel safer and more secure. It is important to balance the client’s need for space with the need for support and reassurance.
Choice D Reason:
Review the updated problem list with the client.
Reviewing the updated problem list is not appropriate during a panic attack. This action requires cognitive engagement and focus, which the client may not be capable of during an acute anxiety episode. The priority during a panic attack is to help the client calm down and manage their immediate symptoms, not to discuss or review problems.
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