The nurse assesses the speech pattern of the patient’s:
Thought content
Thought process
Affect
The Correct Answer is B
Choice A reason:
Thought content refers to the actual ideas and themes that a person expresses. It includes what the person is thinking about, such as delusions, obsessions, or preoccupations. Assessing thought content involves understanding the specific topics and beliefs the patient discusses.
Choice B reason:
Thought process refers to the way in which thoughts are organized and connected. Describing a patient’s speech as hesitant, slow, and with thought blocking indicates issues with the thought process. Thought blocking, where a person’s speech is interrupted by sudden silences, suggests difficulty in maintaining a coherent flow of ideas.
Choice C reason:
Affect refers to the observable expression of emotion. It includes the patient’s facial expressions, tone of voice, and body language. While affect can provide clues about a person’s emotional state, it does not directly relate to the organization of their thoughts.
Choice D reason:
Mood refers to the patient’s sustained emotional state, such as feeling depressed, anxious, or euphoric. While mood can influence speech patterns, the description of hesitant, slow speech with thought blocking specifically pertains to thought process rather than mood.
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Correct Answer is A
Explanation
Choice A reason:
Expressing an active suicide ideation by stating, “I will take an overdose if I return to the dorm room,” meets the criteria for a 5150 involuntary hold for “Danger to Self.” This statement indicates a clear and immediate risk of self-harm, which warrants immediate intervention to ensure Edward’s safety.
Choice B reason:
Starting to cry when discussing his grandfather’s death is a normal emotional response to grief and does not meet the criteria for a 5150 involuntary hold. While it indicates emotional distress, it does not suggest an immediate risk of self-harm.
Choice C reason:
Refusing to take antidepressant medication is concerning and may indicate non-compliance with treatment, but it does not meet the criteria for a 5150 involuntary hold unless it is accompanied by behaviors that indicate an immediate risk of self-harm.
Choice D reason:
Admitting to feeling hopeless but agreeing to return to the clinic in the morning escorted by his classmate who will stay with him does not meet the criteria for a 5150 involuntary hold. While feelings of hopelessness are serious, the plan to return to the clinic with support indicates that Edward is not an immediate danger to himself.
Correct Answer is B
Explanation
Choice A reason:
Saying “If you don’t stop this, you are going to get an infection and I will have to call the doctor” is not an effective way to address Tiffany’s behavior. This statement is likely to increase her anxiety and does not help her understand or manage her triggers.
Choice B reason:
Asking “Can you tell me about what increases your anxiety?” is the best approach. This question is open-ended and non-judgmental, encouraging Tiffany to share her thoughts and feelings. Understanding her triggers is essential for developing effective coping strategies and interventions.
Choice C reason:
Ignoring the behavior and asking other questions is not appropriate. It is important to address Tiffany’s anxiety and compulsive behaviors directly to provide appropriate support and interventions.
Choice D reason:
Asking “Why do you keep washing your hands? They are starting to bleed!” is likely to be perceived as critical and may increase Tiffany’s anxiety. It is important to approach the topic with empathy and understanding, focusing on identifying triggers and developing coping strategies.