Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse overhears a client who has schizophrenia talking to herself. The client keeps stating "The muxtranks are coming. The muntranks are coming. The nurse correctly recognizes the client's use of the word mazuka as an example of which of the following alterations in speech?
A. Neologism
Neologism. Neologism is a language disturbance in which the individual creates new, idiosyncratic words that have meaning only to the individual. In this case, the client's use of "mazuka" is an example of a neologism as it is a made-up word that holds significance only for the client.
B. Clang association
Clang association involves the association of words based on sound rather than meaning.
C. Echolalla
Echolalia is the repetition of words or phrases spoken by others.
D. Word salad
Word salad refers to a jumble of words and phrases that lack coherent meaning or logical connection.
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Full Explanation
A. Neologism.
Neologism is a language disturbance in which the individual creates new, idiosyncratic words that have meaning only to the individual. In this case, the client's use of "mazuka" is an example of a neologism as it is a made-up word that holds significance only for the client.
B. Clang association involves the association of words based on sound rather than meaning.
C. Echolalia is the repetition of words or phrases spoken by others.
D. Word salad refers to a jumble of words and phrases that lack coherent meaning or logical connection.
Similar Questions
A nurse is assisting with the care of a 14-year old client in the emergency department (ED) who has anorexia nervosa.
Nurses’ Notes
Client brought to the ED by parent due to a fainting at home earlier this evening, Parent reports that client has been worried about their weight and been refusing to eat. Parent also reports client has been spending several hours at the local gym. Vitals signs obtained and labs drawn requested by provider.
Which of the following 5 findings require immediate follow-up by the nurse? (Select all that apply.)
A. Sodium level
Sodium level:Abnormal sodium levels can have serious consequences, including neurological symptoms. Immediate follow-up is necessary to assess and manage electrolyte imbalances, as severe cases can lead to complications such as seizures.
B. Phosphate level
Phosphate level:While phosphate levels are important to monitor, they may not require immediate follow-up unless severe abnormalities are present. Severe phosphate imbalances can occur in the context of malnutrition, but they may not necessitate immediate intervention in the ED unless critical.
C. Magnesium level
Magnesium level:Similar to phosphate, magnesium levels are crucial but may not demand immediate follow-up unless severe abnormalities are detected. While magnesium imbalances can occur in eating disorders, the urgency depends on the extent of the imbalance.
D. Respiratory rate
Respiratory rate:Rapid or abnormal respiratory rates can be indicative of respiratory distress, which may occur in individuals with severe anorexia nervosa. Monitoring and addressing respiratory issues promptly are crucial for the client's respiratory function.
E. capillary refill
Capillary refill is included in the list of findings that require immediate follow-up. Prolonged capillary refill time indicates potential issues with peripheral perfusion and warrants prompt attention to assess and address any circulation concerns.
F. Blood pressure
Abnormal blood pressure, especially low blood pressure, can indicate cardiovascular compromise, which is a concern in severe cases of anorexia nervosa. Monitoring and addressing abnormal blood pressure promptly are essential for the client's well-being.
G. Glucose level
Anorexia nervosa can lead to hypoglycemia, and low glucose levels can result in various complications, including neurological symptoms. Immediate follow-up is necessary to assess and manage glucose levels for the well-being of the client
Full Explanation
A. Sodium level:
Abnormal sodium levels can have serious consequences, including neurological symptoms. Immediate follow-up is necessary to assess and manage electrolyte imbalances, as severe cases can lead to complications such as seizures.
B. Phosphate level:
While phosphate levels are important to monitor, they may not require immediate follow-up unless severe abnormalities are present. Severe phosphate imbalances can occur in the context of malnutrition, but they may not necessitate immediate intervention in the ED unless critical.
C. Magnesium level:
Similar to phosphate, magnesium levels are crucial but may not demand immediate follow-up unless severe abnormalities are detected. While magnesium imbalances can occur in eating disorders, the urgency depends on the extent of the imbalance.
D. Respiratory rate:
Rapid or abnormal respiratory rates can be indicative of respiratory distress, which may occur in individuals with severe anorexia nervosa. Monitoring and addressing respiratory issues promptly are crucial for the client's respiratory function.
E. Capillary refill:
Capillary refill is included in the list of findings that require immediate follow-up. Prolonged capillary refill time indicates potential issues with peripheral perfusion and warrants prompt attention to assess and address any circulation concerns.
F. Blood pressure:
Abnormal blood pressure, especially low blood pressure, can indicate cardiovascular compromise, which is a concern in severe cases of anorexia nervosa. Monitoring and addressing abnormal blood pressure promptly are essential for the client's well-being.
G. Glucose level:
Anorexia nervosa can lead to hypoglycemia, and low glucose levels can result in various complications, including neurological symptoms. Immediate follow-up is necessary to assess and manage glucose levels for the well-being of the client
A nurse is reinforcing teaching with a client who is scheduled to receive electroconvulsive therapy (ECT). Which of the following statements should the nurse include in the teaching?
A. "You may experience muscle cramping from the induced seizure."
"You may experience muscle cramping from the induced seizure." While muscle stiffness is possible, the term "muscle cramping" might not accurately describe the postictal state after ECT.
B. The most common adverse effects of ECT are related to anesthesia."
"The most common adverse effects of ECT are related to anesthesia." While anesthesia is used during ECT, the most common adverse effects are related to the ECT procedure itself, such as confusion, memory loss, and headache.
C. "You should expect to have ECT once per week for 6 weeks."
"You should expect to have ECT once per week for 6 weeks." The frequency and duration of ECT treatments vary based on the individual's response and treatment plan. This statement provides a specific schedule that may not apply to all patients.
D. "You might feel a bit confused and disoriented when you first wake up."
"You might feel a bit confused and disoriented when you first wake up." This statement accurately reflects a common and expected postictal effect of ECT. Patients undergoing ECT commonly experience confusion and disorientation upon awakening. This is a temporary and expected side effect of the treatment. It's important for the patient to be aware of this possibility as part of the informed consent process.
Full Explanation
A. "You may experience muscle cramping from the induced seizure." While muscle stiffness is possible, the term "muscle cramping" might not accurately describe the postictal state after ECT.
B. "The most common adverse effects of ECT are related to anesthesia." While anesthesia is used during ECT, the most common adverse effects are related to the ECT procedure itself, such as confusion, memory loss, and headache.
C. "You should expect to have ECT once per week for 6 weeks." The frequency and duration of ECT treatments vary based on the individual's response and treatment plan. This statement provides a specific schedule that may not apply to all patients.
D. "You might feel a bit confused and disoriented when you first wake up." This statement accurately reflects a common and expected postictal effect of ECT. Patients undergoing ECT commonly experience confusion and disorientation upon awakening. This is a temporary and expected side effect of the treatment. It's important for the patient to be aware of this possibility as part of the informed consent process.
A nurse working in a mental health facility is admitting a client.
A nurse is assisting with initiating the client's plan of care. Complete the following sentence by using the list of options (Separate using a comma).
The nurse should first address the client's
Full Explanation
The nurse should first address the client's cardiac status followed by the client's Nutritional status
Explanation:
- Cardiac status: Potassium levels are critically low, which can significantly impact cardiac function.
- Nutritional status: The client has multiple electrolyte imbalances, which could be related to nutrition or absorption issues.