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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A Reason:

Securing the oxygen tubing to the bed sheet near the client’s head is not recommended because it can lead to accidental dislodgement of the tubing, which can interrupt the oxygen supply. Additionally, this practice does not address the potential for nasal dryness and irritation that can occur with oxygen therapy. Properly securing the tubing should involve ensuring it is comfortably positioned and not at risk of being pulled or dislodged.

Choice B Reason:

Attaching a humidifier bottle to the base of the flow meter is the correct action because it helps to add moisture to the oxygen being delivered to the client. Oxygen therapy, especially at higher flow rates like 5 L/min, can dry out the nasal passages and mucous membranes, leading to discomfort and potential complications. The humidifier bottle ensures that the oxygen is humidified, which helps to prevent dryness and irritation, making the therapy more comfortable and effective for the client.

Choice C Reason:

Applying petroleum jelly to the nares is not recommended because petroleum-based products can be flammable and pose a risk when used in conjunction with oxygen therapy. Additionally, petroleum jelly can trap bacteria and potentially lead to infections. Instead, water-based lubricants or saline nasal sprays are safer alternatives for soothing dry nasal passages.

Choice D Reason:

Removing the nasal cannula while the client eats is not advisable because it interrupts the continuous delivery of oxygen, which is essential for clients with pneumonia who may already have compromised respiratory function. Instead, the nurse should ensure that the nasal cannula is securely in place and that the client is receiving the prescribed oxygen therapy at all times, including during meals.

A. Keep the drainage system below the level of the client’s chest at all times. B. Clamp the chest tube prior to transferring the client to a wheelchair. C. Empty the collection chamber prior to transport. D. Disconnect the chest tube from the drainage system during transport.

Correct Answer is A

Explanation

Choice A Reason:

Keep the drainage system below the level of the client’s chest at all times is correct. This measure ensures that gravity assists in the drainage of air and fluid from the pleural space, preventing backflow into the chest cavity. Keeping the drainage system below chest level maintains the negative pressure needed for effective drainage.

Choice B Reason:

Clamp the chest tube prior to transferring the client to a wheelchair is incorrect. Clamping the chest tube can lead to a buildup of air or fluid in the pleural space, potentially causing a tension pneumothorax. The chest tube should remain unclamped to allow continuous drainage.

Choice C Reason:

Empty the collection chamber prior to transport is incorrect. While it is important to monitor and manage the drainage, emptying the collection chamber is not necessary before transport. The focus should be on maintaining the integrity and function of the drainage system.

Choice D Reason:

Disconnect the chest tube from the drainage system during transport is incorrect. Disconnecting the chest tube can lead to a loss of the negative pressure system, resulting in potential complications such as pneumothorax. The chest tube should remain connected to ensure continuous drainage and maintain the negative pressure.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which action should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which measure is important for the nurse to take?

Correct Answer is A

Explanation

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