A nurse is caring for a client who has a mental disorder. Which of the following statements by the client suggests the inability to process new information?
"I need to catch the bird that is flying in my room."
"I feel like someone is watching me."
"I have a difficult time remembering things."
"I am sad no matter how well things are going."
The Correct Answer is C
A. This statement suggests a delusion or hallucination, which are common symptoms of some mental disorders, but it does not specifically suggest an inability to process new information.
B. This statement suggests paranoia, which is a common symptom of some mental disorders, but it does not specifically suggest an inability to process new information.
C. This statement suggests difficulty with memory, which is a cognitive function that is related to the ability to process new information.
D. This statement suggests a persistent negative mood, which is a symptom of some mental disorders, but it does not specifically suggest an inability to process new information.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Rubbing hands and arms to dry is not a step in the hand hygiene process. After washing, the hands should be dried thoroughly with a clean towel or air dryer.
B. Adjusting the water temperature to feel hot is not necessary for effective hand hygiene. The water should be warm, but not hot, to avoid skin damage.
C. Holding the hands higher than the elbows is not a step in the hand hygiene process.
D. Applying 4 to 5 mL of liquid soap to the hands is the correct amount of soap to use for effective hand hygiene. The soap should be rubbed onto the hands and wrists for at least 20 seconds before rinsing thoroughly with water.
Correct Answer is C,A,D,B,E
Explanation
The correct order is C,A,D,B,E.
C. Open the airway using a jaw-thrust maneuver.
This is the first priority since maintaining a clear airway is critical for the client’s survival.
A. Determine effectiveness of ventilatory efforts.
After ensuring the airway is open, assess the client’s breathing and whether they are ventilating effectively.
D. Perform a Glasgow Coma Scale assessment.
This step evaluates the client’s neurological status to determine their level of consciousness and identify any brain injuries.
B. Remove clothing for a thorough assessment.
To expose the client for a comprehensive physical examination and assess any injuries.
E. Control any external bleeding.
As part of circulation management, identify and stop any significant bleeding to prevent shock. This step addresses the "C" in ABCDE.
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