NCLEX Module 4 Exam ALL ANSWERS 100% CORRECT SPRING FALL-2022 SOLUTION GUARANTEED GRADE A+
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NCLEX Module 4
A client with schizophrenia says, “I’m away for the day ... but don’t think we should play or do we have feet of clay?” Which alteration in the client’s speech does the nurse document?
A. Neologism
B. Word salad
C. Clang association Correct
D. Associative looseness
Rationale: Clang a...
“i’m away for the day but don’t think we should play or do we have feet of clay” which alteration in the client’s speech does t
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NCLEX Module 4 Exam ALL ANSWERS 100%
CORRECT SPRING FALL-2022 SOLUTION
GUARANTEED GRADE A+
1. 1.ID: 22114677593
A client with schizophrenia says, “I’m away for the day ... but don’t think we should play
or do we have feet of clay?” Which alteration in the client’s speech does the nurse
document?
A. Neologism
B. Word salad
C. Clang association Correct
D. Associative looseness
Rationale: Clang association is the meaningless rhyming of words in which the rhyming
is more important than the context of the words. A neologism is a made-up word that
has meaning only to the client. Word salad is the term for a mixture of meaningless
phrases, either to the client or to the listener. Associative looseness is a term used to
describe schizophrenic speech in which connections and threads are interrupted or
missing.
Test-Taking Strategy: Knowledge of the speech patterns exhibited by the client with
schizophrenia is needed to answer this question. Focus on the subject in the question,
the meaningless rhyming of words.
Review: these speech patterns .
Reference: Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health
nursing: A communication approach to evidence-based care (p. 281). St. Louis:
Saunders.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Giddens Concepts: Communication, Psychosis
HESI Concepts: Cognition
Awarded 100.0 points out of 100.0 possible points.
2. 2.ID: 22114677590
A client with schizophrenia and his parents are meeting with the nurse. One of the
young man’s parents says to the nurse, “We were stunned when we learned that our
son had schizophrenia. He was no different than from his older brother when they were
growing up. Now he’s had another relapse, and we can’t understand why he stopped his
medication.” Which response by the nurse is appropriate?
A. Telling the parents, “Medication noncompliance is the most
frequent reason that people with this diagnosis relapse.”
B. Telling the parents, “Well, it’s his decision to take his medicine, but
it’s yours to have him live with you if he stops the medication.”
, C. Asking the client, “How can we help you to take your medicine or
to tell us when you’re having problems so that your medication can be
adjusted?” Correct
D. Saying to the parents, “Your concerns are appropriate, but I wonder
whether your son was having trouble telling someone that he had concerns
about his medication.”
Rationale: The therapeutic response is the one in which the nurse models speaking
directly to the client. This facilitates further assessment of the situation and helps elicit
the causes of and motivations for the client’s behavior for both the nurse and the family.
In the correct option, the nurse also seeks clarification of the degree of openness and
mutuality felt by the client and his family toward each other. The nurse provides
information to the family when stating that noncompliance is the most frequent reason
for relapse in people with this diagnosis. However, the statement is nontherapeutic at
this time because it does not facilitate the expression of feelings. The nurse uses a
superego style of communication when stating, “Well, it’s his decision to take his
medicine, but it’s yours to have him live with you if he stops the medication.” The
content of this statement may be true, but it is nontherapeutic in that it carries a
threatening message and may prevent the family from trusting the nurse. By stating,
“Your concerns are appropriate, but I wonder whether your son was having trouble
telling someone that he had concerns about his medication,” the nurse gives approval
and prematurely analyzes the client’s motivation without sufficient assessment.
Test-Taking Strategy: Use your knowledge of therapeutic communication
techniques and remember to focus on the client’s feelings. Also note that the correct
option is the only option in which the nurse directly addresses the client.
Review: therapeutic communication techniques .
Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp.
27-31). St. Louis: Mosby.
Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A
communication approach to evidence-based care (p. 297). St. Louis: Saunders.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Giddens Concepts: Adherence, Psychosis
HESI Concepts: Adherence, Cognition
Awarded 100.0 points out of 100.0 possible points.
3. 3.ID: 22114677587
An acutely ill client with schizophrenia says to the nurse, “He keeps saying that he likes
you, and I keep telling him you’re married, but he won’t listen, and I think he’s going to
get fresh with you.” Once the nurse has determined that the client is hallucinating,
which response to the client would be most appropriate statement?
A. “Try not to listen to the voices right now so that I can talk with
you.” Correct
, B. “I think that you can help him stop his behavior if you
concentrate.”
C. “Tell him I said to mind his p’s and q’s or I’ll call the police on him.”
D. “I think that you’re trying to share your own feelings toward me,
but you’re shy.”
Rationale: The appropriate statement by the nurse is the one that does not
acknowledge the client’s hallucinations. By responding, “I think that you can help him
stop his behavior if you concentrate” or “Tell him I said to mind his p’s and q’s or I’ll call
the police on him,” the nurse acknowledges the hallucinations. The nurse attempts to
interpret the client’s thinking with a statement such as “I think that you’re trying to
share your own feelings toward me, but you’re shy.”
Test-Taking Strategy: Note the strategic words “most appropriate.” Use your
knowledge of therapeutic communication techniques and remember that the nurse
should not acknowledge the client’s hallucinations. Also note that the correct option is
the only one that encourages realistic verbalization from the client.
Review: therapeutic communication techniques with a client who is hallucinating .
References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp.
27-31). St. Louis: Mosby.
Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A
communication approach to evidence-based care (pp. 287, 288). St. Louis: Saunders.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Giddens Concepts: Communication, Psychosis
HESI Concepts: Cognition, Communication
Awarded 100.0 points out of 100.0 possible points.
4. 4.ID: 22114677584
A client says to the nurse, “It’s over for me — the whole thing is over.” Which response
by the nurse would be therapeutic?
A. “What do you mean, ‘The whole thing is over’?”
B. “Over? Well, that sounds pretty drastic to me. Let’s discuss this inthe strictest
confidence.”
C. “Can you tell me more about why it’s over for you? I’ll keep yourthoughts
strictly confidential.”
D. “Let’s talk more about your feeling that the whole thing is over foryou. This is
important, and I may need to share your feelings with other staff members.”
Correct
Rationale: The therapeutic response seeks clarification, employs paraphrasing, and
informs the client that the nurse needs to share any information that requires crisis
intervention with other staff members. Asking, “What do you mean, ‘The whole thing is
over’?” employs paraphrasing, but the message is blunt and closed-ended. In stating,
“Over? Well, that sounds pretty drastic to me. Let’s discuss this in the strictest
, confidence,” the nurse uses hysterical exaggeration (at an inappropriate time) and
gives incorrect information regarding confidentiality. In stating, “Can you tell me more
about why it’s over for you? I’ll keep your thoughts strictly confidential,” the nurse uses
the therapeutic technique of seeking clarification but does not clarify with the client that
the information might need to be shared.
Test-Taking Strategy: Eliminate the comparable or alike options that indicate that
shared information will be maintained as confidential. To select from the remaining
options, focus on the statement that addresses the client’s feelings.
Review: therapeutic communication techniques .
Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp.
27-31). St. Louis: Mosby.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Communication and Documentation
Content Area: Mental Health
Giddens Concepts: Communication, Psychosis
HESI Concepts: Cognition, Communication
Awarded 100.0 points out of 100.0 possible points.
5. 5.ID: 22114677581
The nurse performing a lethality assessment asks the client whether he is thinking of
suicide. Which statement by the client would be of most concern to the nurse?
A. “No, I wasn’t, but I am now, thanks to you.” Correct
B. “I hadn’t thought of that, but I can see that you are.”
C. “Of course not, but there are days when I think that I should be.”
D. “What is suicide going to do for me except get me
excommunicated from the church?”
Rationale: The client’s response that he is now thinking about suicide is of the greatest
concern to the nurse. In making the statement “I hadn’t thought of that, but I can see
that you are” the client projects his own thoughts of suicide onto the nurse. In stating,
“Of course not, but there are days when I think that I should be,” the client is being
sarcastic but is not specifically talking about suicide. In stating, “What is suicide going
to do for me except get me excommunicated from the church?” the client indicates that
suicide is not an option because of his religious beliefs.
Test-Taking Strategy: Note the strategic word “most.” Note the words “but I am
now” in the correct option. This is the only option that identifies definite suicidal
thoughts.
Review: lethality assessment in the suicidal client .
References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp.
27-31). St. Louis: Mosby.
Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A
communication approach to evidence-based care (p. 412). St. Louis: Saunders.
Level of Cognitive Ability: Analyzing
Client Needs: Safe and Effective Care Environment
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