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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Encouraging the patient to drink more fluids is a primary intervention for managing thick respiratory secretions. Adequate hydration helps to thin the mucus, making it easier to expectorate. Fluids such as water, herbal teas, and clear broths are particularly effective. The normal daily fluid intake for an adult is about 2-3 liters, depending on individual needs and health conditions.

Choice B reason: Getting a prescription for an antitussive agent is not the best initial approach for managing thick respiratory secretions. Antitussive agents are used to suppress coughing, which can be counterproductive when trying to clear mucus from the respiratory tract. Instead, expectorants or mucolytics are more appropriate as they help to thin and loosen the mucus.

Choice C reason: Teaching effective deep breathing is beneficial for overall lung health and can help in mobilizing secretions. However, it is not as immediately effective as increasing fluid intake for thinning thick secretions. Deep breathing exercises can be part of a comprehensive respiratory care plan but should be combined with other interventions like hydration.

Choice D reason: Changing the patient’s position every 2 hours is a good practice for preventing complications such as pressure ulcers and promoting lung expansion. However, it is not specifically targeted at thinning thick respiratory secretions. Positional changes can aid in the drainage of secretions but are secondary to ensuring adequate hydration.

A. Sclera B. Dorsal surface of the foot C. Pinnae of the ears D. Palmar surface of the hand

Correct Answer is A

Explanation

Choice A Reason:

Sclera is correct. The sclera, or the white part of the eye, is a reliable site to assess for jaundice, especially in dark-skinned individuals. Jaundice causes a yellowish discoloration of the sclera due to the accumulation of bilirubin in the blood. This yellowing is often more noticeable in the sclera than in other parts of the body.

Choice B Reason:

Dorsal surface of the foot is incorrect. The dorsal surface of the foot is not a reliable site for assessing jaundice, particularly in dark-skinned individuals. The skin on the feet may not show the yellow discoloration as clearly as the sclera.

Choice C Reason:

Pinnae of the ears is incorrect. The pinnae, or outer parts of the ears, are not typically used to assess for jaundice. The skin in this area may not show the yellow discoloration as effectively as the sclera.

Choice D Reason:

Palmar surface of the hand is incorrect. While the palms can sometimes show signs of jaundice, they are not as reliable as the sclera. The yellow discoloration may be less noticeable on the palms, especially in dark-skinned individuals.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 is complaining of thick respiratory secretions that are difficult to clear. What should the nurse encourage the client to do to help clear those secretions?

Correct Answer is A

Explanation

A nurse is assessing for jaundice on a dark-skinned client. Which site should the nurse examine to identify jaundice on this client?

Correct Answer is A

Explanation

A nurse received a prescription to administer a medication NOW to a client. Which action should the nurse take?

A nurse is monitoring the urinary output of a client who had a colon resection. Which 24-hour output total indicates oliguria?

A nurse is assessing a client’s cranial nerves. Which methods should the nurse use to assess cranial nerve V?

A nurse on the medical-surgical unit is conducting a fall risk assessment on four clients. Which of these clients would be at greatest risk for falls?

A nurse is caring for a client who has returned to the unit following a surgical procedure of the abdomen. The client is complaining of pain 6/10. On assessment, the client’s oxygen saturation is 85%. Which action should the nurse take first?

A nurse is assessing a client with congestive heart failure (CHF). Which assessment tool will provide a reliable measure of fluid retention for this client?

An employee health nurse is providing education on how nurses can prevent back and joint injury. Which techniques minimize this risk of injury on the job?

A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The nurse positions the client in the orthopneic position. What is the primary reason for the use of this position for this client?