During an assessment, the nurse asks a client to explain what the following means: "A penny saved is a penny earned." The nurse is assessing which of the following?

Concentration

Attention

Affect

Abstract reasoning

Answer and Explanation

The Correct Answer is D

A.   Concentration refers to the ability to focus on a specific task or thought for a period of time. While concentration is important for cognitive functioning, it is not the specific skill being assessed when interpreting the meaning of a proverb.
B.   Attention is the ability to focus and direct mental resources towards a specific task or stimulus. While attention is necessary for understanding and processing information, the task of interpreting a proverb is more related to higher-level cognitive processes rather than just the ability to maintain focus.
C.   Affect refers to the emotional state or mood of a person. It involves how emotions are expressed and experienced. Assessing affect involves observing the client’s emotional responses, not their ability to interpret abstract concepts. Therefore, affect is not the focus of this assessment.
D.   Abstract reasoning is the ability to understand and interpret concepts and ideas that are not directly observable or tangible. It involves thinking beyond concrete facts to understand underlying meanings, patterns, and relationships. Interpreting a proverb, which involves understanding a figurative meaning rather than a literal one, is a test of abstract reasoning. The ability to grasp the deeper meaning behind “A penny saved is a penny earned” reflects the client's capacity for abstract reasoning.

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Correct Answer is D

Explanation

A. The trigeminal nerve (CN V) is primarily responsible for sensation in the face and the motor control of the muscles used for chewing. It does not have a role in balance or equilibrium, so it would not be the focus when assessing balance issues.
B. The facial nerve (CN VII) controls the muscles of facial expression and provides taste sensation to the anterior two-thirds of the tongue. While it plays a significant role in facial movement and taste, it is not involved in balance or equilibrium.
C. The olfactory nerve (CN I) is responsible for the sense of smell. It does not have any role in balance or equilibrium. Balance issues are not related to the olfactory nerve, so this is not the appropriate focus for balance assessment.
D. The vestibulocochlear nerve (CN VIII) has two major components: the cochlear nerve, which is responsible for hearing, and the vestibular nerve, which is responsible for balance and equilibrium. The vestibular component of CN VIII is crucial for maintaining balance and spatial orientation. When a client reports spontaneous loss of balance, this nerve should be the focus of additional assessment.

A. Coma B. Lethargy C. Obtunded D. Stupor

Correct Answer is B

Explanation

A. Coma is a state of profound unconsciousness where the patient cannot be awakened and does not respond to any stimuli, including verbal commands or physical stimuli.

B. Lethargy is characterized by a state of drowsiness or fatigue where the patient may fall asleep easily but can be roused to respond appropriately when stimulated. The patient shows decreased alertness but is still capable of engaging with stimuli.
C. Obtunded refers to a state where the patient has reduced alertness and responsiveness. They may respond slowly and require increased stimulation to achieve a response. They are less aware of their environment and have dulled senses.
D. Stupor is a state of near-unconsciousness where the patient can only be awakened by vigorous or painful stimuli. They may not respond to verbal commands but may show some response to more intense stimuli.

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During an assessment, the nurse asks a client to explain what the following means: "A penny saved is a penny earned." The nurse is assessing which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an assessment of the cranial nerves, a client reports spontaneously losing balance. The nurse should focus additional assessment on which cranial nerve?

Correct Answer is D

Explanation

A client opens the eyes and answers questions however falls back asleep within seconds. How should the nurse document this assessment finding?

Correct Answer is B

Explanation

Taste in the 1/3 posterior of your tongue is given by:

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