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. Borborygmi refers to the audible rumbling sounds produced by the movement of gas through the intestines. While these sounds may be present in this case, they are more commonly described as prolonged, loud, or audible sounds, not as typical gurgles occurring at the interval described.
B. Hyperactive bowel sounds are frequent and loud, often heard in conditions like diarrhea or early bowel obstruction. The described pattern here, with sounds occurring every 5 to 10 seconds, doesn't necessarily suggest hyperactivity.
C. Hypoactive bowel sounds are reduced or absent, commonly seen in conditions like ileus or bowel obstruction. The sounds described here are not consistent with hypoactive sounds, which would be faint or absent.
D. The description provided aligns with normal bowel sounds, which are intermittent and occur every 5 to 30 seconds in a healthy individual. This pattern of gurgles with the stated frequency is typical of normal bowel function.

Correct Answer is []

Explanation

Condition: Pleural Effusion

Pleural effusion is an accumulation of fluid in the pleural space, leading to difficulty breathing, decreased lung sounds, and dullness upon percussion (as noted in the nurse's assessment).

Actions to Take:

Auscultate the lungs for adventitious breath sounds: Pleural effusion may result in decreased or absent breath sounds due to fluid in the pleural cavity. Adventitious sounds such as crackles or a pleural friction rub can sometimes be heard, but in this case, decreased sounds are noted.
Inspect the chest for lag on the affected side: In pleural effusion, there may be a delay in chest expansion on the affected side due to fluid buildup, which is consistent with the decreased expansion noted in the assessment.

Parameters to Monitor:

Cyanosis: Cyanosis may occur if the fluid accumulation severely impairs oxygenation.
Respiratory rate and pulse: Monitoring respiratory rate and pulse is critical to assess for signs of respiratory distress and hypoxia, which could result from the pleural effusion.

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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

While auscultating for bowel sounds in an adult client, the nurse notes a series of gurgles that last about 3 seconds and occur every 5 to 10 seconds in all quadrants. How should the nurse document this finding?

Correct Answer is D

Explanation

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

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

When assessing an older adult client with a history of cardiovascular disease, dyspnea, and peripheral edema, which method is best for the nurse to use to assess the client's pulse rate?

Which assessment finding, obtained during chest auscultation, should the nurse consider a normal finding?

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