The nurse is caring for a client diagnosed with catatonia. Which of the following should be a priority action by the nurse?

Schedule the client for a therapeutic group session.

Encourage the client to walk in the hallway.

Encourage the client to verbalize feelings at all times.

Offer small, frequent fluids throughout the day.

Answer and Explanation

The Correct Answer is D

Choice A Reason:
Scheduling the client for a therapeutic group session may not be appropriate as a priority action. Clients with catatonia often experience significant psychomotor disturbances, which can include immobility or stupor, making participation in group activities challenging and potentially distressing.

Choice B Reason:
Encouraging the client to walk in the hallway is not the most immediate concern. While mobility is important, the safety and medical stability of the client take precedence, especially considering the potential for immobility and resistance to movement in catatonic states.

Choice C Reason:
Encouraging the client to verbalize feelings at all times is not practical as a priority action. Catatonia can involve mutism or significantly reduced responsiveness, making it difficult for the client to express themselves verbally.

Choice D Reason:
Offering small, frequent fluids throughout the day is a priority action for a client with catatonia. Due to the potential for decreased oral intake and the risk of dehydration, ensuring the client receives adequate hydration is essential. This intervention addresses a basic physiological need and can prevent further complications.

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Correct Answer is B

Explanation

Choice A Reason:
Taking steps to prevent the client from verbalizing delusional thoughts is not therapeutic. It can lead to the client feeling misunderstood and unsupported. Nurses should provide a safe environment where clients feel comfortable expressing their thoughts and feelings.

Choice B Reason:
Allowing the client to select food from vending machines can be a temporary measure to address the immediate concern of the client’s fear of being poisoned. It provides a sense of control over their situation and may help to reduce anxiety related to eating.

Choice C Reason:
Simply explaining that others eat the same food and feel safe may not be effective for a client experiencing delusions. Delusions are fixed beliefs that are not easily changed by logical explanations or evidence to the contrary.

Choice D Reason:
Encouraging the client to discuss why someone would poison the food might validate the delusion and could reinforce the false belief. It’s important to acknowledge the client’s feelings without supporting the delusional content.

A. Associative looseness B. Tangentiality C. Neologism D. Circumstantiality E. Choice C reason:

Correct Answer is C

Explanation

Choice A reason:

Associative looseness refers to a disorganized thought process where connections between ideas are unclear or illogical. The use of the word "flakala" does not demonstrate a loose association between ideas but rather the creation of a new word.

Choice B reason:

Tangentiality occurs when a person goes off on a tangent and does not return to the original topic. In this case, the client is not going off on a tangent but is repeatedly using a made-up word, which is indicative of neologism.

Choice C reason:

Neologism is the creation of new words that others may not understand. The client's use of "flakala" fits this definition, as it appears to be a word created by the client that is not part of standard language¹. This can be a sign of disorganized thinking, where the client's internal thoughts do not align with conventional language patterns.

Choice D reason:

Circumstantiality involves providing unnecessary detail that makes communication less efficient but eventually returns to the original point. The client's statement does not include unnecessary details; it is the repetition of a newly created word, suggesting neologism.

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The nurse is caring for a client diagnosed with catatonia. Which of the following should be a priority action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client in an acute mental health unit. The client states, “I believe my food is poisoned.” Which of the following should be an appropriate action by the nurse?

Correct Answer is B

Explanation

A nurse overhears a client diagnosed with schizophrenia talking to herself. The client keeps stating, "The flakalas are here. The flakalas are here." The nurse should recognize the client's use of the word "flakala" as an example of which of the following alterations in speech?

Correct Answer is C

Explanation

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