A nurse is teaching a client about tactile testing.
Which of the following client statements indicates an understanding of the teaching?
"I will be asked to identify different sensations, such as sharp or dull.”.
"Small needles will be inserted into one of my muscles.”.
"A dye is injected into my vein during this test.”.
"I will be asleep during this test.”.
The Correct Answer is A
Choice A rationale:
The client's statement, "I will be asked to identify different sensations, such as sharp or dull," indicates an understanding of the teaching on tactile testing. This choice demonstrates knowledge about the purpose and nature of the test, which involves identifying various sensations, including sharp or dull, to assess the client's sensory perception. The client's response aligns with the expected outcome of the teaching, showing comprehension.
Choice B rationale:
The statement, "Small needles will be inserted into one of my muscles," is not an accurate description of tactile testing. Tactile testing typically involves assessing the client's ability to perceive sensations on their skin, such as sharpness, dullness, temperature, or pressure. Inserting needles into muscles is not a part of this test, so this choice does not indicate an understanding of the teaching.
Choice C rationale:
The statement, "A dye is injected into my vein during this test," is not related to tactile testing. Tactile testing does not involve injecting dye into veins. This response suggests a misunderstanding of the purpose and procedure of the test, so it is not the correct choice.
Choice D rationale:
The statement, "I will be asleep during this test," is not consistent with tactile testing. Tactile testing is a sensory assessment that requires the client to be awake and actively participate in identifying sensations. This response indicates a lack of understanding of the test, and it is not the correct choice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is
Explanation
Choice A rationale:
Constipation in a client on bedrest is a common issue, and one of the primary interventions is to increase fluid intake. Adequate hydration helps soften the stool, making it easier to pass, and can prevent constipation. This intervention is based on sound nursing principles and is the most appropriate choice.
Choice B rationale:
Encouraging the client to drink cold fluids is not a specific intervention for constipation. While staying hydrated is important, the temperature of the fluids is not as relevant to relieving constipation as the overall fluid intake.
Choice C rationale:
Requesting a prescription for mineral oil is not the first-line intervention for constipation. Mineral oil can have potential side effects and should only be used when other measures have failed. Increasing fluid intake and dietary fiber are typically the initial steps taken.
Choice D rationale:
Placing the client on a low-fiber diet is not an appropriate intervention for constipation. A low-fiber diet can exacerbate constipation by reducing the bulk and softness of the stool. This choice is counterproductive to addressing the issue.
Correct Answer is B
Explanation
Choice A rationale:
Reduced respiratory rate is not a typical manifestation of pain. In fact, pain often leads to an increased respiratory rate as the body responds to discomfort by trying to minimize it.
Choice B rationale:
Elevated blood pressure is a common manifestation of pain. When a person experiences pain, their sympathetic nervous system is activated, leading to an increase in heart rate and blood pressure. This response is designed to prepare the body to fight or flee from a potential threat, and it helps redirect blood flow to vital organs.
Choice C rationale:
Constricted pupils are not a direct manifestation of pain. In contrast, dilated pupils can be seen in response to pain as a result of sympathetic nervous system activation.
Choice D rationale:
Decreased heart rate is not typically associated with pain. Pain tends to increase heart rate as a part of the body's stress response.
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