The nurse asks a female client about the proverb “Glass Houses,” and she replies, “It will break the windows.”. Which conclusion should be documented about this client’s response?

Impaired memory.

Impaired thinking.

Normal mental status for age.

Impaired concentration.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Impaired memory would be indicated by difficulty recalling recent events or information, not by an inability to understand or interpret a proverb.
Choice B rationale
Impaired thinking is suggested by the client’s literal interpretation of the proverb “Glass Houses.”. This indicates difficulty with abstract thinking and understanding figurative language, which can be a sign of cognitive impairment.
Choice C rationale
Normal mental status for age would be indicated by the ability to understand and interpret common proverbs and idioms appropriately. The client’s response does not align with this.
Choice D rationale
Impaired concentration would be indicated by difficulty focusing on tasks or maintaining attention, not by a literal interpretation of a proverb.

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Correct Answer is A

Explanation

Choice A rationale
Describing the client’s exact words, “body-wracking dry cough” of 6 weeks duration, provides a clear and specific account of the client’s symptoms and concerns.
Choice B rationale
Expressing concern of “lung cancer” symptoms for the last 6 weeks is less specific and does not accurately capture the client’s primary symptom, which is the dry cough.
Choice C rationale
Presenting with a hacking nonproductive cough of 6 weeks duration is a clinical interpretation and does not use the client’s own words, which is important for accurate documentation.
Choice D rationale
An adult male presents with fears that he has “lung cancer” is a subjective interpretation and does not accurately describe the client’s primary symptom.

A. Have you been sleeping well? B. Have you ever had problems with your blood sugar? C. Have you had anything to eat in the last 24 hours? D. Have you been depressed lately?

Correct Answer is A

Explanation

Choice A rationale
Assessing the client's sleep patterns can help determine if fatigue or lack of sleep might be contributing to their symptoms of expressionless facial affect, slurred speech, and red conjunctivae. Poor sleep can lead to various physical and cognitive issues that might explain the client's current presentation.
Choice B rationale
Asking about blood sugar issues is also important, but it might not be the first question to ask given the symptoms. Blood sugar imbalances can cause slurred speech and altered mental status, but it's more common to address general factors like sleep first.
Choice C rationale
Asking if the client has had anything to eat in the last 24 hours is relevant for assessing nutritional status and potential hypoglycemia, but it may not provide immediate insight into the underlying cause of the symptoms.
Choice D rationale
Asking if the client has been depressed lately is important for assessing mental health, but it may not directly address the immediate physical symptoms the client is experiencing.

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The nurse asks a female client about the proverb “Glass Houses,” and she replies, “It will break the windows.”. Which conclusion should be documented about this client’s response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae. Which querry should the nurse ask first?

Correct Answer is A

Explanation

The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?

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