A nurse is teaching a client about tactile testing.
Which of the following client statements indicates an understanding of the teaching?
"I will be asked to identify different sensations, such as sharp or dull.”.
"Small needles will be inserted into one of my muscles.”.
"A dye is injected into my vein during this test.”.
"I will be asleep during this test.”.
The Correct Answer is A
Choice A rationale:
The client's statement, "I will be asked to identify different sensations, such as sharp or dull," indicates an understanding of the teaching on tactile testing. This choice demonstrates knowledge about the purpose and nature of the test, which involves identifying various sensations, including sharp or dull, to assess the client's sensory perception. The client's response aligns with the expected outcome of the teaching, showing comprehension.
Choice B rationale:
The statement, "Small needles will be inserted into one of my muscles," is not an accurate description of tactile testing. Tactile testing typically involves assessing the client's ability to perceive sensations on their skin, such as sharpness, dullness, temperature, or pressure. Inserting needles into muscles is not a part of this test, so this choice does not indicate an understanding of the teaching.
Choice C rationale:
The statement, "A dye is injected into my vein during this test," is not related to tactile testing. Tactile testing does not involve injecting dye into veins. This response suggests a misunderstanding of the purpose and procedure of the test, so it is not the correct choice.
Choice D rationale:
The statement, "I will be asleep during this test," is not consistent with tactile testing. Tactile testing is a sensory assessment that requires the client to be awake and actively participate in identifying sensations. This response indicates a lack of understanding of the test, and it is not the correct choice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Full-thickness skin loss with visible adipose tissue is not indicative of a stage 1 pressure injury. A stage 1 pressure injury involves intact skin with localized erythema. Full-thickness skin loss with visible adipose tissue is more characteristic of a stage 2 or higher pressure injury.
Choice B rationale:
Intact skin with localized erythema is the hallmark of a stage 1 pressure injury. In this stage, the skin is still intact, but there is non-blanchable erythema (redness) that indicates tissue damage. There is no full-thickness skin loss, and the underlying structures are not visible.
Choice C rationale:
Full-thickness skin loss with visible bone is not characteristic of a stage 1 pressure injury. This description is more in line with a stage 4 pressure injury, where there is extensive tissue loss, and bone or other underlying structures are visible.
Choice D rationale:
Partial-thickness skin loss with red tissue in the wound bed is not indicative of a stage 1 pressure injury. This description is more typical of a stage 2 pressure injury, where there is partial-thickness skin loss, but the wound bed may contain pink or red tissue without visible adipose tissue.
Correct Answer is D
Explanation
Choice A rationale:
Health education involves providing information and knowledge to clients to help them make informed decisions about their health. It focuses on teaching individuals about health-related topics. In this scenario, the nurse is not engaged in health education but rather in blood pressure screening, which is a form of health assessment and monitoring.
Choice B rationale:
Health promotion involves activities that encourage and empower individuals to take control of their health and well-being. It aims to enhance the overall health of the population. While blood pressure screening is a preventive measure, it does not encompass the broader concept of health promotion. It is more specific to early detection and monitoring of health conditions.
Choice C rationale:
Holistic health refers to an approach that considers the physical, emotional, social, and spiritual aspects of an individual's well-being. It recognizes the interconnectedness of these aspects and seeks to address them in a comprehensive manner. Performing a blood pressure screening, while important, is a specific health assessment task and does not fully encompass the holistic health approach.
Choice D rationale:
Disease prevention involves activities and measures taken to reduce the occurrence and impact of specific diseases. In this scenario, the nurse is performing a blood pressure screening for a client with a family history of hypertension. This screening is a preventive measure aimed at detecting and preventing the development of hypertension, which falls under the category of disease prevention. By identifying clients at risk, healthcare providers can intervene early and implement strategies to prevent or manage the condition. .
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