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?

Normal mental status for age.

Impaired memory.

Impaired concentration.

Impaired thinking.

Answer and Explanation

The Correct Answer is D

A) Normal mental status for age: This response would suggest that the client's cognitive functions are appropriate for her age and educational background, which is not the case here. The response to the proverb "Glass Houses" indicates a lack of understanding or incorrect interpretation, which is not consistent with normal mental status.

B) Impaired memory: Impaired memory would typically manifest as difficulty recalling past events, recent information, or specific details. The client's response to the proverb does not indicate a memory problem but rather a difficulty in interpreting abstract concepts.

C) Impaired concentration: Impaired concentration would usually be indicated by the client's inability to focus on the conversation, becoming easily distracted, or having trouble maintaining attention. The client’s response to the proverb suggests more of a cognitive processing issue rather than an attention issue.

D) Impaired thinking: This is the most accurate conclusion. The client's response to the proverb "Glass Houses" ("It will break the windows") suggests difficulty with abstract thinking and interpreting common proverbs. Proverbs are often used to assess abstract thinking and reasoning abilities. A correct response would typically relate to the proverb's intended meaning about hypocrisy or not criticizing others when you have faults yourself, indicating that the client might have issues with abstract reasoning and impaired thinking.

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Correct Answer is C

Explanation

A) Papules: Papules are small, raised, solid bumps on the skin that are typically less than 1 centimeter in diameter. They can be a result of various skin conditions, but they are not specifically associated with allergic reactions to insect bites.

B) Excoriation: Excoriation refers to a scratch or abrasion on the surface of the skin, often resulting from scratching due to itching. While this can occur secondary to an allergic reaction, it is not a primary characteristic of such reactions.

C) Wheals: Wheals, also known as hives or urticaria, are raised, red or skin-colored welts on the skin that often itch and can appear rapidly in response to an allergen such as an insect bite. They are a characteristic feature of allergic reactions and are caused by the release of histamine.

D) Fissuring: Fissuring refers to deep cracks or splits in the skin. While it can occur in various skin conditions, it is not a typical manifestation of an allergic reaction to an insect bite.

A. Cardiac atrophy. B. Cardiac enlargement. C. Benign variation. D. Expected finding. E. None F. None

Correct Answer is B

Explanation

Answer: B. Cardiac enlargement.

Rationale:

A) Cardiac atrophy:
Cardiac atrophy refers to the reduction in the size of the heart muscles and is not typically detected through percussion. It would present differently, likely through imaging or echocardiography, rather than an increase in the area of dullness during percussion.

B) Cardiac enlargement:
Percussion revealing dullness extending from the 5th left intercostal space upward to the 2nd left intercostal space suggests an increase in the size of the heart. This pattern indicates cardiac enlargement, as the heart’s borders have extended beyond their typical boundaries, which are usually confined to the 5th left intercostal space along the midclavicular line.

C) Benign variation:
A benign variation would not typically cause such a significant change in the area of cardiac dullness. This finding is more concerning for pathology, such as cardiomegaly, than a harmless variation.

D) Expected finding:
The normal borders of the heart should not extend upward to the 2nd left intercostal space during percussion. This finding is not within normal limits and suggests an abnormal enlargement of the heart, rather than an expected physiological outcome.

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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

An adult client exhibits an allergic reaction to an insect bite. The nurse should observe the client's skin for which finding?

Correct Answer is C

Explanation

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

Rationale:

A client presents with itching and pain in the left ear that started several days after beginning swim lessons. The nurse observes a discharge coming from the ear with a musty odor. How should the nurse expect the ear to appear when performing an otoscopic examination?

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?

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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?

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While observing a client's face, which assessment finding requires immediate intervention by the nurse?

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