The nurse asks a female client about the proverb “Glass Houses,” and she replies, “It will break the windows.”. Which conclusion should be documented about this client’s response?
Impaired memory.
Impaired thinking.
Normal mental status for age.
Impaired concentration.
The Correct Answer is B
Choice A rationale
Impaired memory would be indicated by difficulty recalling recent events or information, not by an inability to understand or interpret a proverb.
Choice B rationale
Impaired thinking is suggested by the client’s literal interpretation of the proverb “Glass Houses.”. This indicates difficulty with abstract thinking and understanding figurative language, which can be a sign of cognitive impairment.
Choice C rationale
Normal mental status for age would be indicated by the ability to understand and interpret common proverbs and idioms appropriately. The client’s response does not align with this.
Choice D rationale
Impaired concentration would be indicated by difficulty focusing on tasks or maintaining attention, not by a literal interpretation of a proverb.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Diabetes mellitus can lead to various complications affecting the nails, such as yellowing or thickening due to poor circulation and infections, but it is not typically associated with brittle, concave (spoon-shaped) nails.
Choice B rationale
Iron deficiency anemia is often associated with brittle, spoon-shaped (concave) nails, known as koilonychia. This condition affects the oxygen-carrying capacity of the blood, leading to changes in the nail beds.
Choice C rationale
Coronary heart disease can lead to changes in the nails due to poor circulation, but it is not commonly associated with brittle, concave nails. Other nail changes might include clubbing or cyanosis.
Choice D rationale
Recent candida infection can affect the nails, causing them to become discolored, thickened, or separated from the nail bed, but it does not typically cause the nails to become brittle and concave.
Correct Answer is C
Explanation
Choice A rationale
Restricting activity to bed rest is important but not the most immediate intervention for a client with a high fever and pain during deep palpation.
Choice B rationale
Monitoring urinary output is important but not the most immediate intervention in this scenario.
Choice C rationale
Initiating NPO (nothing by mouth) status is crucial to prepare the client for potential surgical intervention, especially if the pain suggests an acute abdominal condition.
Choice D rationale
Obtaining an electrocardiogram is important but not the most immediate intervention for a client with abdominal pain and high fever.
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