A client says to a nurse, "I can tell that my roommate is always talking about me behind my back." Which term should the nurse document that best describes this client's statement?
A) Word salad
B) Clang association
C) Loose association
D) Ideas of reference
D
You might also like to view...
A patient tells the nurse not to bother with an assessment since the patient's symptoms are "hopeless." This information will cause the nurse to use which type of assessment?
A) Mental health screening B) Appearance and behavior C) Thought and perceptions D) High-yield screening questions
The nurse is planning postoperative care for a patient who is being admitted to the surgical unit form the recovery room after transsphenoidal resection of a pituitary tumor. Which nursing action should be included?
a. Palpate extremities for edema. b. Measure urine volume every hour. c. Check hematocrit every 2 hours for 8 hours. d. Monitor continuous pulse oximetry for 24 hours.
The nurse is preparing to implement plans of care with several clients. Which action would be inappropriate for the nurse to perform?
A) Ask the English-as-a-Second-Language (ESOL) client to state in his or her own words what it means to be NPO. B) Seek input from the family of how the client with aphasia normally communicates at home. C) Respond to the postoperative client's question that baths are given only in the morning. D) Request that family members provide ethnic/cultural foods of the African client's liking.
The nurse must watch for what common complications in a patient who has undergone a transverse rectus abdominis myocutaneous (TRAM) flap?
a. Axillary edema and tissue necrosis b. Delayed wound healing and muscle contractions c. Delayed wound healing and axillary edema d. Delayed wound healing and hematoma