The nurse is caring for a person displaying associative looseness. Which of the following would be the best strategy for the nurse to respond to associative looseness?

Place difficulty in understanding on yourself: “I’m having trouble following you.”

Let the patient think you understand to minimize the patient’s anxiety.

Use reality testing to help the patient clarify their statements.

Tell the patient they are not making any sense in order to set clear expectations.

Answer and Explanation

The Correct Answer is A

A: Placing the difficulty in understanding on yourself by saying, “I’m having trouble following you,” is a therapeutic communication technique. It helps to reduce the patient’s anxiety and encourages them to clarify their thoughts without feeling judged. This approach fosters a supportive environment and can help the patient organize their thoughts better.

B: Letting the patient think you understand to minimize their anxiety is not an effective strategy. It can lead to further confusion and does not help the patient improve their communication. Honesty and clarity are important in therapeutic interactions.

C: Using reality testing to help the patient clarify their statements can be useful, but it may not be the best initial approach. It requires the patient to have some level of insight and ability to engage in reality testing, which may not be possible in severe cases of associative looseness.

D: Telling the patient they are not making any sense can be perceived as judgmental and may increase the patient’s anxiety and frustration. It is not a supportive or therapeutic approach and can hinder effective communication.

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Free Nursing Study Resources

Correct Answer is A,B,C,D

Explanation

The correct answer is:

A. Stabilize fluid, electrolyte levels, address dysrhythmia

B. Initiate adequate calories for age, height and metabolic need

C. Develop more effective coping skills to deal with anxiety

D. Verbalizes body shape and weight as normal and acceptable

Stabilize fluid, electrolyte levels, address dysrhythmia: This is the most urgent priority because imbalances in fluids and electrolytes, as well as dysrhythmias, can be life-threatening. Immediate medical intervention is necessary to stabilize the patient’s condition and prevent serious complications.

Initiate adequate calories for age, height and metabolic need: Once the patient’s immediate medical needs are addressed, the next priority is to ensure they receive adequate nutrition. This step is crucial for weight restoration and overall health improvement, which are essential for recovery from anorexia nervosa.

Develop more effective coping skills to deal with anxiety: After addressing the physical health concerns, the focus can shift to psychological aspects. Developing coping skills to manage anxiety is important for long-term recovery and preventing relapse. Anxiety often underlies eating disorders, so addressing it is key to comprehensive treatment.

Verbalizes body shape and weight as normal and acceptable: This outcome is important for the patient’s self-perception and long-term recovery. However, it is the least urgent compared to the immediate medical and nutritional needs. It can be addressed once the patient is medically stable and has begun to develop coping mechanisms.

A. Cocaine abuser with chest pain B. An intoxicated client with a long history of alcoholism C. A client who recently experienced a “bad trip” from LSD D. A young man who thinks they have been given flunitrazepam (Rohypnol)

Correct Answer is A

Explanation

A: A cocaine abuser with chest pain should be assessed first because chest pain can indicate a life-threatening condition such as a myocardial infarction (heart attack). Cocaine use increases the risk of cardiovascular events, making this client a priority.

B: An intoxicated client with a long history of alcoholism needs medical attention, but their condition is likely less immediately life-threatening compared to chest pain from cocaine use.

C: A client who recently experienced a “bad trip” from LSD may be experiencing psychological distress, but this is generally not as immediately life-threatening as chest pain.

D: A young man who thinks they have been given flunitrazepam (Rohypnol) needs to be assessed for potential drug-facilitated assault, but this situation is less immediately critical than chest pain from cocaine use.

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The nurse is caring for a person displaying associative looseness. Which of the following would be the best strategy for the nurse to respond to associative looseness?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is developing a plan of care for the client newly diagnosed with anorexia nervosa who is receiving inpatient treatment. According to the client needs, prioritize the outcomes from most urgent to least urgent.

Correct Answer is A,B,C,D

Explanation

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Correct Answer is A

Explanation

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