A nurse is collecting data from a newly admitted client. Which of the following questions should the nurse ask to assess the client's abstract thinking ability?

"Who is the current President of the United States?"

"What does the phrase 'butterflies in my stomach' mean?"

"Can you count backward from 20 to 1?"

"Can you draw a clock that shows the hands at 4:30?"

Answer and Explanation

The Correct Answer is B

A. Asking about the current President of the United States assesses the client's orientation to time and place but does not directly assess abstract thinking.
B. Asking what the phrase 'butterflies in my stomach' means assesses the client's ability to

interpret and understand abstract concepts, as it requires the client to interpret a metaphorical expression.
C. Asking the client to count backward from 20 to 1 assesses attention and concentration but does not directly assess abstract thinking.
D. Asking the client to draw a clock that shows the hands at 4:30 assesses cognitive function, spatial orientation, and memory but does not directly assess abstract thinking.

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Correct Answer is B

Explanation

A. Encouraging the client to talk about current events may not be effective, as individuals with Alzheimer's disease may have difficulty following complex conversations or remembering recent events.
B. Giving directions using simple phrases is essential for effective communication with individuals who have Alzheimer's disease. Using clear, concise language helps reduce confusion and frustration and improves the client's ability to understand and follow instructions.
C. Orienting the client to time and place twice per day can be helpful for some individuals with Alzheimer's disease, but the frequency and method of orientation may vary depending on the client's specific needs and preferences. It may not be necessary to orient the client twice per day in all cases.
D. While it's important to provide consistent care to clients with Alzheimer's disease, rotating assistive personnel frequently may lead to confusion and distress for the client. Consistency and familiarity with caregivers can help establish trust and improve the client's sense of security.

A. Cleanse the perineal area from back to front. B. Wash the perineal area with povidone-iodine twice daily. C. Change the perineal pad with each void. D. Wipe the perineal area with a soft towel. E. Wipe the perineal area with a soft towel.

Correct Answer is C

Explanation

A. Cleansing the perineal area from back to front can introduce bacteria from the rectum to the urinary tract, increasing the risk of infection. Front to back is the recommended direction for cleansing.
B. Washing the perineal area with povidone-iodine twice daily may be too frequent and could potentially irritate the area. Gentle cleansing with warm water is typically recommended.
C. Changing the perineal pad with each void helps to maintain cleanliness and prevent infection by reducing the buildup of moisture and bacteria.
D. Wiping the perineal area with a soft towel is appropriate for gentle cleansing but does not address the importance of changing the perineal pad regularly.

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A nurse is collecting data from a newly admitted client. Which of the following questions should the nurse ask to assess the client's abstract thinking ability?

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