A nurse is caring for a client brought to the emergency room. The client’s caregiver reports the client had a sudden onset of confusion. Which intervening technique by the nurse is most appropriate to evaluate mentation for this client?

Ask close-ended questions.

Ask open-ended questions.

Use directive questions.

Use reflective questions.

Answer and Explanation

The Correct Answer is B

Choice A Reason:

Ask close-ended questions is incorrect. Close-ended questions typically elicit short, specific responses such as “yes” or “no.” While they can be useful in certain situations, they do not provide enough information to thoroughly assess a client’s mental status. Open-ended questions allow the client to express themselves more fully, providing the nurse with better insight into their cognitive function.

Choice B Reason:

Ask open-ended questions is correct. Open-ended questions encourage the client to elaborate on their thoughts and feelings, which can reveal more about their mental status. This type of questioning helps the nurse assess the client’s orientation, memory, and thought processes more effectively.

Choice C Reason:

Use directive questions is incorrect. Directive questions are more structured and guide the client towards specific answers. While they can be useful for obtaining specific information, they do not allow for a comprehensive assessment of the client’s mental status.

Choice D Reason:

Use reflective questions is incorrect. Reflective questions are used to encourage the client to think more deeply about their responses and feelings. While they can be helpful in therapeutic settings, they are not the most effective for an initial assessment of mental status.

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Correct Answer is B

Explanation

Choice A reason: A history of hypothyroidism is not a contraindication for magnet therapy. Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormone, but it does not interfere with the use of magnetic fields. Therefore, patients with hypothyroidism can safely use magnet therapy.

Choice B reason: Having a pacemaker is a significant contraindication for magnet therapy. Magnetic fields can interfere with the functioning of pacemakers, potentially leading to serious complications. Patients with pacemakers should avoid magnet therapy to prevent any risk of device malfunction.

Choice C reason: A history of narcolepsy is not a contraindication for magnet therapy. Narcolepsy is a neurological disorder that affects the control of sleep and wakefulness, but it does not interact with magnetic fields. Therefore, patients with narcolepsy can use magnet therapy without concern.

Choice D reason: An indwelling catheter is not a contraindication for magnet therapy. Indwelling catheters are used for urinary drainage and do not interact with magnetic fields4. Patients with indwelling catheters can safely undergo magnet therapy.

A. Encourage the patient to drink more fluids. B. Get a prescription for an antitussive agent. C. Teach effective deep breathing. D. Change the patient’s position every 2 hours.

Correct Answer is A

Explanation

Choice A reason: Encouraging the patient to drink more fluids is a primary intervention for managing thick respiratory secretions. Adequate hydration helps to thin the mucus, making it easier to expectorate. Fluids such as water, herbal teas, and clear broths are particularly effective. The normal daily fluid intake for an adult is about 2-3 liters, depending on individual needs and health conditions.

Choice B reason: Getting a prescription for an antitussive agent is not the best initial approach for managing thick respiratory secretions. Antitussive agents are used to suppress coughing, which can be counterproductive when trying to clear mucus from the respiratory tract. Instead, expectorants or mucolytics are more appropriate as they help to thin and loosen the mucus.

Choice C reason: Teaching effective deep breathing is beneficial for overall lung health and can help in mobilizing secretions. However, it is not as immediately effective as increasing fluid intake for thinning thick secretions. Deep breathing exercises can be part of a comprehensive respiratory care plan but should be combined with other interventions like hydration.

Choice D reason: Changing the patient’s position every 2 hours is a good practice for preventing complications such as pressure ulcers and promoting lung expansion. However, it is not specifically targeted at thinning thick respiratory secretions. Positional changes can aid in the drainage of secretions but are secondary to ensuring adequate hydration.

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A nurse is caring for a client brought to the emergency room. The client’s caregiver reports the client had a sudden onset of confusion. Which intervening technique by the nurse is most appropriate to evaluate mentation for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client wants to start doing magnet therapy. The nurse should explain to the client, which would be a contraindication for the use of magnet therapy?

Correct Answer is B

Explanation

A nurse is caring for a client who is complaining of thick respiratory secretions that are difficult to clear. What should the nurse encourage the client to do to help clear those secretions?

Correct Answer is A

Explanation

A nurse accidentally sticks her hand with a needle after administering an intramuscular (IM) injection to a client. Which action should the nurse take first?

A client has an injury to the left ankle requiring partial weight bearing. The client is elderly with a history of balance deficit. Which assistive device would be most appropriate for this client?

A nurse is assessing a client with congestive heart failure (CHF). Which assessment tool will provide a reliable measure of fluid retention for this client?

A nurse is providing teaching to a postoperative client regarding diet. Which nutrient is responsible for maintaining healthy bowel elimination?

Edited TextA nurse is auditing a client. During the assessment, the nurse notes the client has multiple cavities, chipped, and missing teeth. The client reports having difficulty eating. Which diet should the nurse recommend the primary health care provider to order for this client?

A nurse is auscultating a client’s lung sounds and identifies crackles in the left lower lobe. Which intervention should the nurse take first?

A nurse is assessing a client’s cranial nerves. What cranial nerve would be assessed when checking a client’s gag reflex?

A nurse is doing hourly rounding and finds a client unresponsive. The nurse is unable to obtain a pulse and the client is not breathing. What intervention would be the priority for this client?