#mental health nursing
The nurse formulates a nursing diagnosis of impaired social interaction related to disorganized thinking for a client with schizotypal personality disorder. Based on this nursing diagnosis, which nursing intervention takes highest priority?
a) Helping the client to participate in social interactions
b) Establishing a one-on-one relationship with the client
c) Exploring the effects of the client’s behavior on social interactions
d) Developing a schedule for the client’s participation in social interactions
Answer: b
By establishing a one-on-one relationship, the nurse helps the client learn how to interact with people in new situations. The other options are appropriate but should take place only after the nurse-client relationship is established.
The nurse is performing a mental status examination on a client, and the client states, “Glass breaks if you throw stones or shoot at it with a gun. My cousin shoots guns at the police all the time at target practice. People who live in glass houses shouldn’t throw stones.” Which interpretation by the nurse is appropriate?
a) Speech is incoherent and tangential.
b) Speech is illogical and loosely associated.
c) Speech is distractible and contains flight of ideas.
d) Speech is pressured and contains clang associations.
Answer: b
Loose associations are speech patterns in which there is a lack of a logical relationship between thoughts and ideas; this causes speech and thought to seem inexact, vague, unfocused, and diffuse. Incoherence is characterized by speech that cannot be understood. Tangential speech refers to an inappropriate response to a statement in which the content of the statement is disregarded. Flight of ideas is overproductive speech, characterized by the client’s quickly switching from one subject to another. Clanging is a form of rhyming that is not comprehensible; a client whose speech features clanging seems to be caught up in the sound of the words.
