Term 2 - PrepU Chapter 10

Term 2 - PrepU Chapter 10 A 29-year-old woman comes to the office. During history taking, the nurse notices that the client is speaking very quickly and jumping from topic to topic so rapidly that it is difficult to f ...

Term 2 - PrepU Chapter 10 A 29-year-old woman comes to the office. During history taking, the nurse notices that the client is speaking very quickly and jumping from topic to topic so rapidly that it is difficult to follow her. The nurse can find some connections between ideas, but it is difficult. Which word best describes this thought process? ans: Flight of ideas (This represents flight of ideas, because the ideas are connected in some logical way. Derailment, or loosening of associations, has more disconnection within clauses.) When assessing the client's ability to make sound judgments, what question should the nurse ask? ans: "How do you plan to pay rent if you lose your job?" The nurse is admitting a client with substance abuse. What screening tool would be best to use if this client is in denial about his substance abuse? ans: CAGE questionnaire (When screening for substance abuse, the client may deny the problem. The CAGE tool is valuable because it addresses this denial. The tool is a quick first-step questionnaire to use.) An older patient is demonstrating mental status changes. Which question would the nurse use for a mini-mental state examination of this patient? ans: "What is the date?" (The mini-mental state examination is a brief test used to screen for cognitive dysfunction or dementia over time.) A new nurse asks the charge nurse what the Mini-Mental Status Examination tests. What is the appropriate response by the charge nurse? ans: "A quick tool that is useful to examine the orientation, memory, speech, and cognitive functions" (The Mini-Mental Status Examination is a quick standard measure to evaluate a person's orientation, memory, speech, and cognitive functions.) The nurse is performing an initial mental status examination on a client with depression. To obtain subjective data, what is the best question made by the nurse? ans: "Tell me how you are feeling right now?" A nurse is admitting a client with self-inflicted lacerations to the arms and abdomen. The nurse also notes healed, small, circular scars on the client's arms. What nursing interventions should the nurse include in the plan of care for this client? (Select all that apply.) ans: • Provide medical treatment for the lacerations. • Have the client contract with staff to notify them when there is a desire to mutilate. A 22-year-old man is brought to the office by his father. The client was diagnosed with schizophrenia 6 months ago and has been taking medication since. The father states that his son's dose isn't high enough and needs to be increased. He states that his son has been hearing things that don't exist. The nurse asks the young man what is going on. He says that his father is just jealous because his sister only talks to him. His father turns to him and says, "Son, you know your sister died 2 years ago!" His son