Author Question: The nurse is performing an assessment of the hospitalized client. After speaking with the client, ... (Read 89 times)

Alainaaa8 · **on:** Jun 25, 2018

The nurse 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 statements by the client validate the nurse's conclusion?

1. When I was little I had four 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.

Question 2

The client is comatose and the healthcare provider orders that the client's temperature is to be taken by the rectal route. The student nurse is assisting the more experienced nurse and volunteers to obtain the client's temperature.

Which statement by the student nurse indicates the need for further education prior to monitoring a rectal temperature?
1. I will need to turn the client into the prone position.
2. The probe for a rectal thermometer is usually red.
3. I should insert the thermometer 1.5 to 4 centimeters into the client's anus.
4. This is an appropriate way to monitor a client's temperature if they are unable to close the mouth around the oral thermometer.

yuyiding · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 1
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. The client who is unable to communicate ideas easily is exhibiting circumlocution. It would have been easier for the client to state that she wished her mother would visit more frequently. The client who is unable to communicate an idea that makes sense in the context of the situation is exhibiting word salad (schizophasia). The client who is experiencing pain may not feel like communicating with the nurse. This is not an example of altered thought processes. It would be appropriate for the client to feel that the healthcare provider should visit the client more often than once in 3 days.

Answer to Question 2

Correct Answer: 1
The client should be turned to the side, not the prone position. The rectal thermometer probe is usually red to signify that it is different from an oral thermometer probe. The thermometer should be placed 1.5 to 4 centimeters into the client's anus. This route may be used if the client is unable to close his or her mouth around an oral thermometer probe.