The nurse is obtaining the mental health history of a newly admitted client diagnosed with schizophrenia. The client's family reports the client is hearing voices and cannot stay focused on the topic of a discussion. Which thought disturbance is the client demonstrating?

Delusions of reference

Tangentiality

Neologism

Loose associations

Answer and Explanation

The Correct Answer is D

A) Incorrect. Delusions of reference involve a belief that everyday events, objects, or other people have a particular and unusual significance. This is not described in the scenario.

B) Incorrect. Tangentiality is a thought disorder where the individual goes off on tangents and never returns to the original point or idea. This is not described in the scenario.

C) Incorrect. Neologism refers to the creation of new words or phrases that have meaning only to the person using them. This is not described in the scenario.

D) Correct. Loose associations are characterized by a disruption in the logical progression of thought, where thoughts become disorganized and may seem unrelated or loosely connected.

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Correct Answer is D

Explanation

A. Orienting the client to the unit While orientation is important, the client's prolonged
immobility and stupor necessitate a physical assessment first to ensure there are no underlying medical issues contributing to this state.

B. Reinforcing reality with the client The client's catatonic state may make it difficult to effectively communicate or engage in reality orientation at this point. Addressing potential physical issues is the initial priority.

C. Establishing a nonthreatening relationship Building a therapeutic relationship is crucial, but given the client's current state, assessing for physical problems takes precedence.

D. Assessing the client for physical problems The client's prolonged catatonic state requires an
immediate physical assessment to rule out any underlying medical conditions contributing to his condition.

A. Label the bathroom door. B. Take the older adult to the bathroom hourly. C. Place the older adult in disposable adult briefs. D. Limit the intake of oral fluids to 1000 mL/day.

Correct Answer is A

Explanation

A. Labeling the bathroom door can provide a visual cue to help the older adult locate the bathroom, which may reduce episodes of incontinence.
B. Taking the older adult to the bathroom hourly is a good strategy, but it may not always be feasible or effective in preventing accidents.
C. Using disposable adult briefs may be necessary at times, but it should not be the first line intervention.
D. Limiting oral fluids to 1000 mL/day may lead to dehydration and is not an appropriate intervention for addressing incontinence.

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The nurse is obtaining the mental health history of a newly admitted client diagnosed with schizophrenia. The client's family reports the client is hearing voices and cannot stay focused on the topic of a discussion. Which thought disturbance is the client demonstrating?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 28-year old male admitted with catatonic schizophrenia has been mute and motionless for several days while at home prior to admission. He still appears stuporous in the hospital. Which nursing intervention would be an initial priority?

Correct Answer is D

Explanation

An older adult in the middle and late stages of Alzheimer's forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the client's family?

Correct Answer is A

Explanation

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