During the scheduled assessment of a patient who is experiencing ...

[piesebel]

During the scheduled assessment of a patient who is experiencing acute alcohol withdrawal, the nurse has identified that the patient does not know where he is and that he feels like there are bugs crawling on his forearms.
 
  The nurse would document the presence of what?
 
  A) Olfactory hallucinations and delusions
  B) Perseveration and lack of orientation
  C) Looseness of association and lack of insight
  D) Disorientation and tactile hallucinations

Question 2

The nurse has entered a hospital patient's room and asked him if he plans to attend the morning's scheduled group life-skills session. Which of the following responses should signal the presence of thought blocking to the nurse?
 
  A) Warning, warning, watch your back.
  B) I might. I'll give it some.
  C) Well, that's certainly the end of that.
  D) The client makes eye contact with the nurse but does not respond verbally.

[Beatricemm]

Answer to Question 1

Ans: D
The fact that an individual does not know his or her present location constitutes a lack of orientation; feeling a sense of touch from an object that is not present is an example of a tactile hallucination.

Answer to Question 2

Ans: B
Blocking refers to a sudden stoppage in the spontaneous flow or stream of thinking or speaking for no apparent external or environmental reason. Clanging involves perceived similarities in meaning between words of similar sound (morning; warning). Mutism is the absence of a verbal response.