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 C

Explanation

A. The Michigan Alcohol Screening Test (MAST) is a tool used to screen for alcohol abuse or dependence, but it does not specifically assess withdrawal symptoms.

B. The CAGE questionnaire is used to screen for alcohol abuse, but it does not assess withdrawal symptoms.
C. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) is a validated tool used to assess the severity of alcohol withdrawal symptoms. It includes various criteria such as agitation, tremor, and hallucinations.
D. The Delirium Rating Scale (DMSE) is used to assess the severity of delirium, which can be caused by various factors including alcohol withdrawal, but it is not specific to alcohol withdrawal.

A. Plan to discuss any topic that is presented. B. Focus on client weaknesses to increase adaptation. C. Provide continuity of care by assigning the same staff. D. Allow client to determine the boundaries of the nurse client relationship.

Correct Answer is C

Explanation

A) Incorrect. While discussing various topics is important, providing continuity of care is more crucial in creating a therapeutic environment for clients with paranoia and schizophrenia.

B) Incorrect. Focusing on client strengths rather than weaknesses is generally a more effective approach in mental health care.

C) Correct. Providing continuity of care by assigning the same staff helps build trust and a sense of security for clients, especially those with paranoia and schizophrenia.
D) Incorrect. While it's important to establish boundaries, allowing the client to solely determine them may not always be in their best interest.

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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

While conducting an admission interview with a client, the nurse suspects the client may be in alcohol withdrawal. Which screening tool can help the nurse identify the severity of withdrawal symptoms?

Correct Answer is C

Explanation

A nurse is planning to run a group for clients diagnosed with paranoia and schizophrenia on an acute care mental health unit. Which of the following actions should the nurse plan to take to create a therapeutic environment?

Correct Answer is C

Explanation

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?

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