Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client on an acute mental health unit states to a nurse, "Tie a bow.
Row the boat.
Now I know.
Whoa! I see you, yo." The nurse should document that the client is exhibiting which of the following speech alterations?
A. Neologisms.
Neologisms involve the creation of new, meaningless words that are not understood by others. The client is using real words, so this pattern does not reflect newly invented language.
B. Echolalia.
Echolalia refers to the repetition of words or phrases spoken by others. The client’s speech is not repeating another person’s words but instead shows a pattern based on sound.
C. Word salad.
Word salad is characterized by completely disorganized, incoherent speech with no logical or grammatical connection between words. Although unusual, the client’s speech maintains structure and is linked by sound patterns rather than being entirely random.
D. Clang associations.
Clang associations occur when speech is driven by the sound of words, such as rhyming or punning, rather than meaning. The client’s use of rhyming phrases like “bow,” “boat,” “know,” and “yo” demonstrates this pattern clearly.
This question is an excerpt from Nurse Dive's nursing test bank - RN Comprehensive Online Practice 2019 B with NGN Proctored Exam. Take the full exam now
Full Explanation
A. Neologisms involve the creation of new, meaningless words that are not understood by others. The client is using real words, so this pattern does not reflect newly invented language.
B. Echolalia refers to the repetition of words or phrases spoken by others. The client’s speech is not repeating another person’s words but instead shows a pattern based on sound.
C. Word salad is characterized by completely disorganized, incoherent speech with no logical or grammatical connection between words. Although unusual, the client’s speech maintains structure and is linked by sound patterns rather than being entirely random.
D. Clang associations occur when speech is driven by the sound of words, such as rhyming or punning, rather than meaning. The client’s use of rhyming phrases like “bow,” “boat,” “know,” and “yo” demonstrates this pattern clearly.
Similar Questions
A nurse is teaching about how to suppress lactation with a client who is postpartum and bottle-feeding her newborn.
Which of the following instructions should the nurse include in the teaching?
A. "You should limit your fluid intake to 1 liter per day.”
Limiting fluid intake to 1 liter per day can lead to dehydration and other health complications. It is important for the client to maintain adequate hydration, especially postpartum. This option is incorrect and potentially harmful.
B. "You should manually express milk when engorgement occurs.”
Manual expression of milk can help relieve engorgement without stimulating further milk production. This method allows the client to express milk as needed. However, it can be done even before engorgment occurs
C. "You should wear a snug-fitting bra continuously for 72 hours.”
Wearing a snug-fitting bra can provide support and comfort.
D. "You should apply moist heat to your breasts four times per day.”
Applying moist heat to the breasts can stimulate milk production and relieve engorgement. However, in this case, the client wants to suppress lactation. Therefore, this option is not appropriate and may have the opposite effect of increasing milk production.
Full Explanation
Choice A rationale:
Limiting fluid intake to 1 liter per day can lead to dehydration and other health complications. It is important for the client to maintain adequate hydration, especially postpartum. This option is incorrect and potentially harmful.
Choice B rationale:
Manual expression of milk can help relieve engorgement without stimulating further milk production. This method allows the client to express milk as needed. However, it can be done even before engorgment occurs
Choice C rationale:
Wearing a snug-fitting bra can provide support and comfort.
Choice D rationale:
Applying moist heat to the breasts can stimulate milk production and relieve engorgement. However, in this case, the client wants to suppress lactation. Therefore, this option is not appropriate and may have the opposite effect of increasing milk production.
A nurse is preparing to insert an indwelling urinary catheter for a client.
Which of the following actions should the nurse take first?
A. Attach a prefilled syringe to the catheter inflation hub.
Attaching a prefilled syringe to the catheter inflation hub is a step performed after the catheter insertion to inflate the balloon, securing the catheter in the bladder. This action is not the first step and should not be done before cleansing the meatus and positioning the sterile drape.
B. Position the sterile drape leaving the perineum exposed.
Positioning the sterile drape leaving the perineum exposed is a necessary step in maintaining the sterility of the procedure area. However, it is not the first action the nurse should take. Cleaning the client's meatus with an antiseptic solution is the initial step to prevent infection during catheter insertion.
C. Cleanse the client's meatus with antiseptic solution.
Cleaning the client's meatus with antiseptic solution is the first step in inserting an indwelling urinary catheter. This action helps to reduce the risk of urinary tract infection by minimizing the introduction of bacteria into the urethra.
D. Lubricate the catheter with water-soluble gel.
Lubricating the catheter with water-soluble gel is a step performed after cleansing the meatus and positioning the sterile drape. It facilitates the smooth insertion of the catheter into the urethra. However, it is not the first action to be taken.
Full Explanation
Choice A rationale:
Attaching a prefilled syringe to the catheter inflation hub is a step performed after the catheter insertion to inflate the balloon, securing the catheter in the bladder. This action is not the first step and should not be done before cleansing the meatus and positioning the sterile drape.
Choice B rationale:
Positioning the sterile drape leaving the perineum exposed is a necessary step in maintaining the sterility of the procedure area. However, it is not the first action the nurse should take. Cleaning the client's meatus with an antiseptic solution is the initial step to prevent infection during catheter insertion.
Choice C rationale:
Cleaning the client's meatus with antiseptic solution is the first step in inserting an indwelling urinary catheter. This action helps to reduce the risk of urinary tract infection by minimizing the introduction of bacteria into the urethra.
Choice D rationale:
Lubricating the catheter with water-soluble gel is a step performed after cleansing the meatus and positioning the sterile drape. It facilitates the smooth insertion of the catheter into the urethra. However, it is not the first action to be taken.
A nurse is providing dietary teaching to the guardian of a preschooler who has celiac disease.
Which of the following foods should the nurse recommend including in the preschooler's diet?
A. Corn tortilla with black beans.
Preschoolers with celiac disease need to avoid gluten-containing grains such as wheat, barley, and rye. Corn tortilla with black beans is a suitable option as it does not contain gluten and provides essential nutrients.
B. Whole wheat pasta with shrimp.
Whole wheat pasta contains gluten, which should be avoided by individuals with celiac disease. This option is inappropriate for the preschooler with celiac disease.
C. Low sodium vegetable soup with barley.
Low sodium vegetable soup with barley contains gluten, which is not suitable for a child with celiac disease. Barley is a gluten-containing grain and should be avoided.
D. A bologna sandwich on rye bread.
Rye bread contains gluten and is not appropriate for a preschooler with celiac disease. This option is not suitable for the child's dietary needs.
Full Explanation
Choice A rationale:
Preschoolers with celiac disease need to avoid gluten-containing grains such as wheat, barley, and rye. Corn tortilla with black beans is a suitable option as it does not contain gluten and provides essential nutrients.
Choice B rationale:
Whole wheat pasta contains gluten, which should be avoided by individuals with celiac disease. This option is inappropriate for the preschooler with celiac disease.
Choice C rationale:
Low sodium vegetable soup with barley contains gluten, which is not suitable for a child with celiac disease. Barley is a gluten-containing grain and should be avoided.
Choice D rationale:
Rye bread contains gluten and is not appropriate for a preschooler with celiac disease. This option is not suitable for the child's dietary needs.