The nurse plans to assess a client's ability to think abstractly. Which question or statement is likely to provide the best information about the client's abstract thinking?

"Count backwards by 7, starting with 100."

"What does, "The early bird catches the worm," mean?"

"Has anyone come to visit you today?"

"In what year were you born?"

Answer and Explanation

The Correct Answer is B

A.   This tests the client’s ability to perform mathematical tasks but does not specifically assess abstract
thinking. It is more of a concrete cognitive task.

B.   This question assesses abstract thinking because it requires the client to interpret a proverb, which involves understanding symbolic meaning beyond the literal words.
C.   This question is assessing more of the client’s orientation and memory rather than abstract thinking. It does not test higher-level cognitive abilities.
D.   This is an orientation question, assessing the client’s ability to recall personal facts, but it does not
assess abstract reasoning skills.

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Correct Answer is B

Explanation

A. This statement could indicate exercise intolerance or shortness of breath with exertion, but it doesn't specifically relate to orthopnea. Orthopnea refers to difficulty breathing when lying flat, not with activity.
B. This statement is indicative of orthopnea. People with orthopnea often need to sleep with multiple pillows or sit up to relieve the shortness of breath they experience when lying flat, often due to heart failure or other respiratory conditions.
C. Nighttime coughing can be a symptom of various conditions, such as asthma or postnasal drip, but it is not specific to orthopnea. Orthopnea is more about difficulty breathing while lying down.
D. Wheezing is a sign of asthma or other respiratory conditions but does not directly correlate with orthopnea. Orthopnea is specifically about the inability to breathe comfortably when lying down, not about wheezing.

A. Record the findings as a normal response. B. Determine if the client has a history of heart disease. C. Obtain the client's blood pressure. D. Compare the apical pulse force to the carotid pulse force.

Correct Answer is B

Explanation

A. If the apical impulse is more vigorous than expected, it may indicate an abnormal finding, such as hyperdynamic circulation or heart failure. The nurse should not simply record this without further investigation.
B. It is important to investigate whether the client has a history of heart disease, as conditions like left ventricular hypertrophy, heart failure, or valvular heart disease could cause changes in the apical impulse. This provides context for understanding the findings.
C. Obtaining the client’s blood pressure is important in assessing cardiovascular health, but the most immediate response to a more vigorous apical impulse would be to explore the potential cause, including heart disease, rather than simply measuring blood pressure.
D. Comparing the apical pulse to the carotid pulse may help assess if the increased pulse force is generalized or localized, and whether it might be a sign of circulatory changes. This would help clarify whether the finding is normal or indicative of pathology.

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The nurse plans to assess a client's ability to think abstractly. Which question or statement is likely to provide the best information about the client's abstract thinking?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which subjective assessment data supports the nurse's conclusion that a client is experiencing orthopnea?

Correct Answer is B

Explanation

During the precordium assessment, the nurse palpates the apical impulse of a client on the 5th intercostal space left mid-clavicular line. The pulse is more vigorous than expected. Which action should the nurse take in response to this finding?

Correct Answer is B

Explanation

An adult male client tells the nurse that he smokes approximately one pack of cigarettes daily. How can the nurse expect smoking to affect this client's sleep?

The nurse is performing oral inspection of a client with dark pigmented skin. The nurse observes a patchy discoloration of the buccal mucosa. Which action should the nurse take?

Which finding, obtained during a skin assessment, should the school nurse report to the healthcare provider?

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