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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale
Tenderness upon palpation of the thoracic region is an abnormal finding and may indicate inflammation, infection, or other pathological conditions.
Choice B rationale
A thrill is a palpable vibration over the chest wall, often associated with turbulent blood flow due to cardiac abnormalities. It is not a normal finding in the thoracic region.
Choice C rationale
Non-tenderness upon palpation of the thoracic region is a normal finding, indicating the absence of inflammation, infection, or other abnormalities.
Choice D rationale
Crepitus is a crackling or popping sensation felt under the skin, often due to the presence of air in the subcutaneous tissue. It is not a normal finding and may indicate conditions such as pneumothorax or subcutaneous emphysema.

A. Inspection of head and neck is observed in a straight alignment without lateral curves. B. Evaluation of cranial nerve XI reveals flexion is maintained against full resistance. C. Palpation of the spinous processes and surrounding muscles are non-tender. D. Observation of cervical range of motion reveals flexion and extension is 25 degrees.

Correct Answer is D

Explanation

A. Inspection of head and neck is observed in a straight alignment without lateral curves: A straight, well-aligned cervical spine is normal and does not indicate a need for further assessment of lifestyle habits.

B. Evaluation of cranial nerve XI (spinal accessory nerve) reveals flexion is maintained against full resistance:This indicates normal strength of the sternocleidomastoid and trapezius muscles, meaning there is no concern related to lifestyle habits.

C. Palpation of the spinous processes and surrounding muscles are non-tender: The absence of tenderness suggests that there is no acute inflammation, injury, or muscle strain, making further lifestyle inquiries unnecessary.

D. Observation of cervical range of motion reveals flexion and extension is 25 degrees:Normal cervical flexion and extension range from 45 to 90 degrees. A limitation to only 25 degrees suggests restricted mobility, which could be due to poor posture, occupational strain, prolonged screen time, or underlying musculoskeletal conditions.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse completes palpation of the thoracic region on an adult client. Which finding is considered normal for this client?

Correct Answer is C

Explanation

The nurse assesses a client who comes to the clinic with neck stiffness and discomfort. Which finding of the cervical spine should the nurse inquire further about lifestyle habits?

Correct Answer is D

Explanation

Heart sounds are loudest for S1 at the ______ and S2 at the _____.

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