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 D

Explanation

A. Tympany indicates the presence of gas within the intestines. This would not be expected over the liver area if there is hepatomegaly.
B. This is not an expected finding in hepatomegaly. Tympany is associated with air-filled structures, which would not be present over an enlarged liver.
C. A hollow sound is also indicative of air-filled organs like the intestines. It is not a sign of hepatomegaly, which would be characterized by dullness on percussion.
D. Dullness upon percussion outside the costal margins suggests an enlarged liver (hepatomegaly). This is due to the liver becoming larger and filling the space that normally contains air-filled organs like the intestines.

A. Palpating in the wrong abdominal quadrant. B. The gallbladder is normal. C. The client is too obese. D. Deeper palpation technique is needed.

Correct Answer is C

Explanation

A. While it is important to palpate the correct quadrant, this is unlikely the cause if the gallbladder cannot be located. The gallbladder is typically located in the right upper quadrant, and the nurse would have been palpating this area. This option does not address the most likely cause.
B. A normal gallbladder might not always be palpable, especially if the client is obese. However, inability to palpate the gallbladder does not necessarily indicate a problem; this is a common finding in obese individuals where fat tissue can obscure the gallbladder.
C. Obesity can make it more difficult to palpate internal structures such as the gallbladder. Excess adipose tissue in the abdominal area can prevent the nurse from feeling the gallbladder during palpation. This is the most likely explanation for the failure to locate the gallbladder.
D. While deeper palpation might be necessary in obese clients, the inability to palpate the gallbladder is more likely due to the obscuring effects of fat, rather than a technique issue. It's a common finding that obesity hinders the ability to palpate organs like the gallbladder.

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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?

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Naxlex Comprehensive Predictor Exams

While completing an admission assessment for a client with fatigue, weakness, and unexplained weight loss, the nurse notes scleral jaundice. Which finding during percussion of the abdomen should the nurse document indicating hepatomegaly?

Correct Answer is D

Explanation

While assessing a client who is obese, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. Which is the most likely explanation for failure to locate the gallbladder by palpation?

Correct Answer is C

Explanation

The nurse begins a client's musculoskeletal assessment. While using the technique of inspection, the nurse assesses for which possible findings? Select all that apply.

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