While conducting an assessment the nurse suspects that a client is making up things in response to specific questions. What behavior is this client demonstrating?
perseveration
flight of ideas
derailment
confabulation
negative Babinski reflex
The Correct Answer is D
A. Perseveration refers to the repetition of a particular response or behavior despite the cessation of the stimulus that prompted it. This often occurs in individuals with neurological disorders, where they keep repeating the same word, phrase, or action.
B. Flight of ideas is a rapid flow of thoughts where the person moves quickly from one topic to another, often with tangential or disconnected ideas. It is commonly observed in conditions such as mania or hypomania.
C. Derailment, also known as loosening of associations, is a thought disorder where a person’s speech goes off-topic and seems disorganized. The connections between ideas are loose or fragmented, making the conversation difficult to follow.
D. Confabulation is a memory disturbance where a person creates false memories or fabricated details to fill in gaps in their memory. The individual does not intentionally deceive but genuinely believes their fabricated information is true.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. The Kernig sign is a clinical test used to diagnose meningitis, not stroke. It involves flexing the patient’s hip and knee and then attempting to extend the knee while the hip is flexed. Pain or resistance during this maneuver can suggest meningeal irritation.
B. Arm weakness refers to the loss of strength or control in one or both arms, which can be a sign of a stroke. It may be noticeable when a person is unable to lift their arm or keep it raised.
C. Sudden confusion, trouble understanding, or difficulty speaking can be signs of a stroke. This may involve problems with language or comprehension, which are related to the areas of the brain responsible for these functions.
D. Face drooping, especially on one side of the face, is a classic sign of stroke. It occurs when the muscles on one side of the face weaken or become paralyzed.
E. The Babinski reflex is a test where the sole of the foot is stroked, and the normal response in adults is the downward flexion of the toes. An abnormal Babinski reflex (upward extension of the big toe) can indicate neurological problems but is not a specific warning sign of stroke.
F. Speech difficulty, such as slurred speech or trouble finding words, is a common sign of a stroke. It can involve problems with articulation, coherence, or understanding language.
Correct Answer is B
Explanation
A. The sternoclavicular joint is where the sternum (breastbone) meets the clavicle (collarbone). It plays a role in the movement of the shoulder girdle but does not involve the jaw. Issues with this joint would typically present as shoulder or chest discomfort rather than problems with the jaw.
B. The temporomandibular joint is the joint where the mandible (lower jaw) meets the temporal bone of the skull, just in front of the ear. It is crucial for jaw movement, including opening, closing, and chewing. If a client feels that their jaws are "stuck," it is likely related to a problem with the TMJ. Common issues include TMJ disorders, which can cause pain, limited movement, or a sensation of the jaw being stuck.
C. The subtalar joint is located in the ankle, between the talus and calcaneus bones. It is involved in the movement of the foot, particularly in inversion and eversion. This joint is unrelated to jaw function, so problems here would affect the foot rather than the jaw.
D. The radioulnar joints are located in the forearm and involve the radius and ulna bones. These joints are responsible for the rotation of the forearm, such as turning the palm up or down. They do not relate to jaw movement or problems, so issues with these joints would affect the forearm or wrist rather than the jaw.
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