A nurse is caring for a client brought to the emergency room. The client’s caregiver reports the client had a sudden onset of confusion. Which intervening technique by the nurse is most appropriate to evaluate mentation for this client?
Ask close-ended questions.
Ask open-ended questions.
Use directive questions.
Use reflective questions.
The Correct Answer is B
Choice A Reason:
Ask close-ended questions is incorrect. Close-ended questions typically elicit short, specific responses such as “yes” or “no.” While they can be useful in certain situations, they do not provide enough information to thoroughly assess a client’s mental status. Open-ended questions allow the client to express themselves more fully, providing the nurse with better insight into their cognitive function.
Choice B Reason:
Ask open-ended questions is correct. Open-ended questions encourage the client to elaborate on their thoughts and feelings, which can reveal more about their mental status. This type of questioning helps the nurse assess the client’s orientation, memory, and thought processes more effectively.
Choice C Reason:
Use directive questions is incorrect. Directive questions are more structured and guide the client towards specific answers. While they can be useful for obtaining specific information, they do not allow for a comprehensive assessment of the client’s mental status.
Choice D Reason:
Use reflective questions is incorrect. Reflective questions are used to encourage the client to think more deeply about their responses and feelings. While they can be helpful in therapeutic settings, they are not the most effective for an initial assessment of mental status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Asthma
Diphenhydramine is an antihistamine that can cause drying of the airways and thickening of bronchial secretions, which might exacerbate asthma symptoms. However, it is not strictly contraindicated in asthma patients. Instead, caution is advised, and it should be used under medical supervision if necessary.
Choice B reason: Hypertension
While diphenhydramine can cause mild increases in blood pressure due to its anticholinergic effects, it is not contraindicated in patients with hypertension. Patients with hypertension should use it cautiously and under medical advice, but it is not an absolute contraindication.
Choice C reason: Glaucoma
Diphenhydramine is contraindicated in patients with glaucoma, particularly closed-angle glaucoma. This is because diphenhydramine has anticholinergic properties that can increase intraocular pressure, potentially worsening the condition. Patients with glaucoma should avoid using diphenhydramine to prevent complications related to increased eye pressure.
Choice D reason: Depression
Diphenhydramine is not contraindicated in patients with depression. However, it can cause drowsiness and sedation, which might affect mood and energy levels. Patients with depression should use it cautiously and under medical supervision, but it is not an absolute contraindication.
Correct Answer is A
Explanation
Choice A Reason:
Fiber is correct. Fiber is essential for maintaining healthy bowel elimination. It helps to add bulk to the stool and promotes regular bowel movements. There are two types of fiber: soluble and insoluble. Soluble fiber absorbs water and forms a gel-like substance, which helps soften the stool and make it easier to pass. Insoluble fiber adds bulk to the stool and helps it move through the digestive tract more quickly.
Choice B Reason:
Fat is incorrect. While fats are an important part of a balanced diet, they do not play a primary role in maintaining healthy bowel elimination. Fats are essential for energy and the absorption of fat-soluble vitamins, but they do not have the same effect on bowel movements as fiber.
Choice C Reason:
Protein is incorrect. Protein is crucial for building and repairing tissues, but it does not directly influence bowel elimination. A diet high in protein without adequate fiber can sometimes lead to constipation.
Choice D Reason:
Minerals are incorrect. Minerals are vital for various bodily functions, including bone health, fluid balance, and muscle function. However, they do not directly impact bowel elimination in the same way that fiber does.
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