HESI Saunders Online Review for the NCLEX-RN Examination 2 Year, 3rd Edition Module 4 Exam.
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Course
MED SURG NU-333
Institution
MED SURG NU-333
A client with schizophrenia says, “I’m away for the day ... but don’t think we
should play or do we have feet of clay?” Which alteration in the client’s speech
does the nurse document?
Neologism
Word salad
Clang association Correct
Associative looseness
Rationale: C...
A client with schizophrenia says, “I’m away for the day ... but don’t think we
should play or do we have feet of clay?” Which alteration in the client’s speech
does the nurse document?
Neologism
Word salad
Clang association Correct
Associative looseness
Rationale: Clang association is the meaningless rhyming of words in which the
rhyming is more important than the context of the words. A neologism is a made-
up word that has meaning only to the client. Word salad is the term for a mixture
of meaningless phrases, either to the client or to the listener. Associative
looseness is a term used to describe schizophrenic speech in which connections
and threads are interrupted or missing.
Test-Taking Strategy: Knowledge of the speech patterns exhibited by the client
with schizophrenia is needed to answer this question. Focus on the subject in the
question, the meaningless rhyming of words.
Review: these speech patterns .
Reference: Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental
health nursing: A communication approach to evidence-based care (p. 281). St.
Louis: Saunders.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Giddens Concepts: Communication, Psychosis
HESI Concepts: Cognition
Awarded 100.0 points out of 100.0 possible points.
,2. 2.ID: 21083973127
A client with schizophrenia and his parents are meeting with the nurse. One of the
young man’s parents says to the nurse, “We were stunned when we learned that
our son had schizophrenia. He was no different than from his older brother when
they were growing up. Now he’s had another relapse, and we can’t understand
why he stopped his medication.” Which response by the nurse is appropriate?
Telling the parents, “Medication noncompliance is the most frequent
reason that people with this diagnosis relapse.”
Telling the parents, “Well, it’s his decision to take his medicine, but
it’s yours to have him live with you if he stops the medication.”
Asking the client, “How can we help you to take your medicine or to
tell us when you’re having problems so that your medication can be
adjusted?” Correct
Saying to the parents, “Your concerns are appropriate, but I wonder
whether your son was having trouble telling someone that he had concerns
about his medication.”
Rationale: The therapeutic response is the one in which the nurse models
speaking directly to the client. This facilitates further assessment of the situation
and helps elicit the causes of and motivations for the client’s behavior for both the
nurse and the family. In the correct option, the nurse also seeks clarification of the
degree of openness and mutuality felt by the client and his family toward each
other. The nurse provides information to the family when stating that
noncompliance is the most frequent reason for relapse in people with this
diagnosis. However, the statement is nontherapeutic at this time because it does
not facilitate the expression of feelings. The nurse uses a superego style of
communication when stating, “Well, it’s his decision to take his medicine, but it’s
yours to have him live with you if he stops the medication.” The content of this
statement may be true, but it is nontherapeutic in that it carries a threatening
message and may prevent the family from trusting the nurse. By stating, “Your
concerns are appropriate, but I wonder whether your son was having trouble
telling someone that he had concerns about his medication,” the nurse gives
approval and prematurely analyzes the client’s motivation without sufficient
assessment.
Test-Taking Strategy: Use your knowledge of therapeutic communication
techniques and remember to focus on the client’s feelings. Also note that the
correct option is the only option in which the nurse directly addresses the client.
Review: therapeutic communication techniques .
Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th
ed., pp. 27-31). St. Louis: Mosby.
Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health
nursing: A communication approach to evidence-based care (p. 297). St. Louis:
, Saunders.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Giddens Concepts: Adherence, Psychosis
HESI Concepts: Adherence, Cognition
Awarded 100.0 points out of 100.0 possible points.
3. 3.ID: 21083973124
An acutely ill client with schizophrenia says to the nurse, “He keeps saying that
he likes you, and I keep telling him you’re married, but he won’t listen, and I
think he’s going to get fresh with you.” Once the nurse has determined that the
client is hallucinating, which response to the client would be most appropriate
statement?
“Try not to listen to the voices right now so that I can talk with you.”
Correct
“I think that you can help him stop his behavior if you concentrate.”
“Tell him I said to mind his p’s and q’s or I’ll call the police on him.”
“I think that you’re trying to share your own feelings toward me,
but you’re shy.”
Rationale: The appropriate statement by the nurse is the one that does not
acknowledge the client’s hallucinations. By responding, “I think that you can help
him stop his behavior if you concentrate” or “Tell him I said to mind his p’s and
q’s or I’ll call the police on him,” the nurse acknowledges the hallucinations. The
nurse attempts to interpret the client’s thinking with a statement such as “I think
that you’re trying to share your own feelings toward me, but you’re shy.”
Test-Taking Strategy: Note the strategic words “most appropriate.” Use your
knowledge of therapeutic communication techniques and remember that the
nurse should not acknowledge the client’s hallucinations. Also note that the
correct option is the only one that encourages realistic verbalization from the
client.
Review: therapeutic communication techniques with a client who is hallucinating
.
References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th
ed., pp. 27-31). St. Louis: Mosby.
Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health
nursing: A communication approach to evidence-based care (pp. 287, 288). St.
Louis: Saunders.
Level of Cognitive Ability: Applying
, Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Giddens Concepts: Communication, Psychosis
HESI Concepts: Cognition, Communication
Awarded 100.0 points out of 100.0 possible points.
4. 4.ID: 21083973121
A client says to the nurse, “It’s over for me — the whole thing is over.” Which
response by the nurse would be therapeutic?
“What do you mean, ‘The whole thing is over’?”
“Over? Well, that sounds pretty drastic to me. Let’s discuss this in the
strictest confidence.”
“Can you tell me more about why it’s over for you? I’ll keep your
thoughts strictly confidential.”
“Let’s talk more about your feeling that the whole thing is over for
you. This is important, and I may need to share your feelings with other
staff members.” Correct
Rationale: The therapeutic response seeks clarification, employs paraphrasing,
and informs the client that the nurse needs to share any information that requires
crisis intervention with other staff members. Asking, “What do you mean, ‘The
whole thing is over’?” employs paraphrasing, but the message is blunt and closed-
ended. In stating, “Over? Well, that sounds pretty drastic to me. Let’s discuss this
in the strictest confidence,” the nurse uses hysterical exaggeration (at an
inappropriate time) and gives incorrect information regarding confidentiality. In
stating, “Can you tell me more about why it’s over for you? I’ll keep your
thoughts strictly confidential,” the nurse uses the therapeutic technique of seeking
clarification but does not clarify with the client that the information might need to
be shared.
Test-Taking Strategy: Eliminate the comparable or alike options that indicate
that shared information will be maintained as confidential. To select from the
remaining options, focus on the statement that addresses the client’s feelings.
Review: therapeutic communication techniques .
Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th
ed., pp. 27-31). St. Louis: Mosby.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Communication and Documentation
Content Area: Mental Health
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