Answer to Question 1
Ans: C
The client is exhibiting referential thinking, that is, the belief that neutral stimuli, such as the radio, have special meaning to that person, such that the radio commentator is talking directly to him. Autistic thinking involves restriction of thinking to the literal and immediate, so that the individual has private rules of logic and reasoning that make no sense to anyone else. Concrete thinking reflects a lack of abstraction in thinking with the inability to understand punch lines, metaphors, and analogies. Illusional thinking occurs when a person misperceives or exaggerates stimuli that actually exist in the external environment.
Answer to Question 2
Ans: D
The nurse should document the client's speech pattern as echolalia, or parrot-like and inappropriate repetition of another's words. Echopraxia refers to an involuntary imitation of another person's movements or gestures. Neologisms are made-up words that have no common meaning and are not recognized. Tangentiality is a disorganized thinking pattern in which the topic of conversation changes to an entirely different topic; the change is a logical progression but causes a permanent detour from the original focus.
A, A nurse is adding a medication to an IV line as a piggyback
B, The nurse teaches the postoperative client to use an incentive spirometer to expand the lungs.
The surgical nurse assists the client into the correct position
A client is having an endoscopy performed by a physician who views the upper gastrointestinal intern
The nurse conveys attentive listening through a posture of involvement
Client positioned and draped