During an admission assessment, which approach should the nurse use to assess a client's speech patterns?

Have the client repeat a phrase containing alliteration

Note the client's responses during the initial interview

Ask the client to complete a common proverb or saying

Listen while the client reads items listed on the menu

Answer and Explanation

The Correct Answer is B

A. Having the client repeat a phrase containing alliteration can assess articulation and phonation but does not provide a comprehensive evaluation of overall speech patterns, including fluency, coherence, and comprehension.
B. Noting the client's responses during the initial interview is an effective way to assess speech patterns in a natural, conversational context. This approach allows the nurse to evaluate the client's language use, coherence, and any speech abnormalities.
C. Asking the client to complete a common proverb or saying can assess abstract thinking and cognitive function but is not specifically aimed at evaluating speech patterns such as fluency or coherence.
D. Listening while the client reads items listed on the menu might assess reading ability and articulation but does not provide a full assessment of conversational speech patterns or the ability to express thoughts coherently.

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Correct Answer is B

Explanation

A. Cardiac atrophy would typically not present with an area of dullness upon percussion. Instead, you might expect a different set of findings related to the heart's size and function.
B. Cardiac enlargement is indicated by an area of dullness that extends beyond the normal borders of the heart. Dullness on percussion indicates the presence of solid or fluid-filled structures, such as an enlarged heart.
C. A benign variation in heart sounds or borders is usually within normal limits and does not typically show such pronounced changes in percussion notes.
D. This finding is not an expected normal finding. Normal heart borders are not usually marked by an area of dullness extending from the 5th to the 2nd intercostal space.

A. Paresthesia. B. Normal sensory finding. C. Marginal decline in sensory function. D. Rebound reaction to the needle points.

Correct Answer is B

Explanation

A. Paresthesia refers to abnormal sensations such as tingling or numbness, which are not indicated by this test result.
B. The ability to sense two points at a distance of 3 mm on the fingertips and 10 mm on the palms is within the normal range for two-point discrimination. Fingertips typically have a higher density of sensory receptors, allowing for finer discrimination.
C. A marginal decline in sensory function would involve a noticeable decrease in the ability to differentiate two points, but this client's results are within normal limits.
D. A rebound reaction refers to a different phenomenon, typically involving reflexes, and is not related to the two-point discrimination test.

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During an admission assessment, which approach should the nurse use to assess a client's speech patterns?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While percussing the borders of the heart, the nurse picks up an area of dullness beginning at the 5th left intercostal space and moving upward to the 2nd left intercostal space at the sternal border. What do these findings indicate?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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