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 A
Explanation
Choice A reason: Guided meditation and other nonpharmacological pain interventions can help reduce the perception of pain, which may allow for lower doses of pain management medications. This is beneficial as it can reduce the risk of side effects and dependency associated with higher doses of pain medications1. Studies have shown that integrating nonpharmacological methods like guided meditation can enhance overall pain management and improve the quality of life for patients2.
Choice B reason: Guided meditation is a complementary therapy and is not intended to replace pain medications entirely. While it can significantly aid in pain management, it is typically used alongside pharmacological treatments to provide a holistic approach to pain relief3. Relying solely on guided meditation without appropriate medical supervision and medication can lead to inadequate pain control.
Choice C reason: Guided meditation is not limited to hospital settings or licensed therapists. Many guided meditation resources are available online, through apps, or in community centers, making it accessible to a broader audience4. Patients can practice guided meditation at home, which provides flexibility and convenience in managing chronic pain.
Choice D reason: Pain medications are often prescribed on a regular schedule to maintain consistent pain control, especially in chronic pain conditions. While nonpharmacological interventions can reduce the need for frequent dosing, they do not eliminate the necessity for scheduled pain medications5. It is essential to follow a healthcare provider’s recommendations for medication administration to ensure effective pain management.
Correct Answer is D
Explanation
Choice A reason: To provide a means for medication administration
A Jackson-Pratt (JP) drain is not used for medication administration. Its primary function is to remove fluids that accumulate in a surgical site, which helps to prevent infection and promote healing. Medication administration is typically done through other means such as intravenous (IV) lines or oral medications.
Choice B reason: To eliminate the need for wound dressings
The JP drain does not eliminate the need for wound dressings. Dressings are still required to protect the wound site, absorb any additional drainage, and prevent infection. The JP drain works in conjunction with dressings to manage wound care effectively.
Choice C reason: To limit the amount of bleeding from the surgical site
While the JP drain can help manage bleeding by removing accumulated blood, its primary purpose is not to limit bleeding. Instead, it is designed to prevent the buildup of fluids, including blood, which can lead to complications such as hematomas or infections.
Choice D reason: To prevent fluid from accumulating in the wound
The primary purpose of a Jackson-Pratt (JP) drain is to prevent fluid from accumulating in the wound. This includes blood, lymphatic fluid, and other bodily fluids that can collect at the surgical site. By removing these fluids, the JP drain helps to reduce the risk of infection, promote healing, and decrease the likelihood of complications.
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