The client is performing an assessment of the hospitalized client. After speaking with the client, the nurse believes that the client is demonstrating altered thought processes
Which of the following statements by the client validate the nurse's conclusion? Standard Text: Select all that apply. 1. "When I was little I had 4 cats. Can I wear a dress instead of this hospital gown?"
2. "I wish that my grandmother's daughter would visit me more often.".
3. "I have never had so much pain. I just don't feel like speaking with you right now.".
4. "My doctor has only been to visit me once during the last three days. I'm starting to feel angry that she hasn't come to see if I'm doing better.".
5. "Red squirrels dance on the divine divide.".
1,2,5
Rationale 1: "When I was little I had 4 cats. Can I wear a dress instead of this hospital gown?" The client who frequently jumps from one subject to another is exhibiting a flight of ideas. Flight of ideas is associated with altered thought processes.
Rationale 2: "I wish that my grandmother's daughter would visit me more often.". The client who is unable to communicate ideas easily is exhibiting circumlocution. It would've been easier for the client to state that he or she wished her mother would visit more frequently.
Rationale 3: "I have never had so much pain. I just don't feel like speaking with you right now.". The client who is experiencing pain may not feel like communicating with the nurse. This is not an example of altered thought processes.
Rationale 4: "My doctor has only been to visit me once during the last 3 days. I'm starting to feel angry that she hasn't come to see if I'm doing better.". It would be appropriate for the client to feel that the healthcare provider should visit the client more often than once in three days. This statement does not indicate that the client is experiencing altered thought processes.
Rationale 5: "Red squirrels dance on the divine divide.". The client who is unable to communicate an idea that makes sense in the context of the situation is exhibiting word salad.
You might also like to view...
The nurse needs to take a blood pressure on a very thin client, and the only cuff available is a standard size. Which type of blood pressure reading does the nurse expect?
1. An accurate reading. 2. A falsely elevated reading. 3. The reading will depend on the overall health of the client. 4. A false low reading.
Upon checking a medication order, the nurse notices that the dosage is more than three times the normal range for this medication. The nurse calls the primary health care provider to question the order
Which critical thinking attitude did the nurse use? a. Confidence b. Risk taking c. Fairness d. Curiosity
The nurse is caring for a client on a hospice unit who has been diagnosed with terminal cancer. The plan of care might include the use of which complementary therapies to help reduce the client's cancer pain? (Select all that apply.)
a. relaxation d. yoga b. imagery e. healing touch c. movement and exer-cise f. biofeedback
The client elects to receive Gardasil. The client chooses to begin the drug series in January. The nurse plans the client's schedule of administration, recognizing that which would be the correct time and route for the client to receive the medication?
a. Subcutaneous injections given in January, February, and March b. Intramuscular injections given in January, March, and June c. Tablets given in January, March, and May d. Tablets given in January, February, and March