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
Normal mental status for age
Impaired concentration
Impaired thinking
The Correct Answer is D
A. Impaired memory refers to difficulty in recalling information or events. The client's response does not indicate an issue with memory recall but rather reflects a misinterpretation of the proverb, suggesting that memory impairment is not the correct conclusion.
B. Normal mental status for age would imply that the client's cognitive responses are appropriate for their developmental stage. However, the client's response to the proverb is not consistent with a normal interpretation, indicating that this option is incorrect.
C. Impaired concentration refers to an inability to maintain focus on a task or thought. While concentration issues might lead to incomplete or disjointed responses, the client's answer does not suggest a lack of focus but rather a misinterpretation, which is more indicative of impaired thinking.
D. Impaired thinking is characterized by difficulty in reasoning, understanding, or interpreting information correctly. The client's response to the proverb "Glass Houses" reflects a concrete interpretation rather than the abstract reasoning typically required to understand proverbs, indicating impaired thinking.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Blood urea nitrogen (BUN) levels may be elevated in cases of gastrointestinal bleeding due to the breakdown of blood in the intestines, but it is not the primary test to monitor for blood loss.
B. Glucose levels are important to monitor for clients with diabetes or metabolic disorders, but they are not directly related to melena, which is a sign of gastrointestinal bleeding.
C. Hematocrit is a critical lab test to monitor in response to melena, as it measures the proportion of red blood cells in the blood. A decrease in hematocrit indicates blood loss, which is a common consequence of gastrointestinal bleeding.
D. White blood cell count (WBC) is used to monitor infection or inflammation, but it is not directly related to the immediate concern of blood loss associated with melena.
Correct Answer is B
Explanation
A. Closed-ended questions typically yield short, specific responses and may not provide enough detail about the sputum's characteristics.
B. Open-ended questioning encourages the client to describe their symptoms in their own words, allowing for more detailed information about the sputum, including color, consistency, and any associated symptoms.
C. Leading questions may suggest a particular answer and can bias the client’s response, leading to inaccurate or incomplete information.
D. Detailed questions about a symptom are useful but may be more appropriate after the client has given an initial description in response to an open-ended question.
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