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 C

Explanation

Choice A rationale
Offering to administer a laxative prescribed for PRN use is not appropriate in this situation, as the presence of rebound tenderness suggests a more serious underlying condition, such as appendicitis.
Choice B rationale
Obtaining a prescription to catheterize the client’s bladder is not indicated, as the symptoms are related to abdominal pain and rebound tenderness, not urinary retention.
Choice C rationale
Notifying the healthcare provider of the rebound tenderness is the appropriate action, as this finding could indicate a serious condition such as appendicitis. Prompt medical evaluation and intervention are necessary.
Choice D rationale
Instructing the client in distraction and relaxation techniques may help manage pain, but it does not address the underlying cause of the rebound tenderness. Immediate medical evaluation is required.

A. Give the client 8 ounces (236.5 mL) of water to drink. B. Send the sample for laboratory evaluation. C. Instruct the client to attempt to urinate again. D. Evaluate the client for bladder distention.

Correct Answer is D

Explanation

Choice A rationale
Giving the client 8 ounces (236.5 mL) of water to drink may help in obtaining a urine sample, but it does not address the immediate concern of potential bladder distention.
Choice B rationale
Sending the sample for laboratory evaluation is not appropriate when the sample is insufficient. The nurse should first address the underlying issue of why the client could not provide an adequate sample.
Choice C rationale
Instructing the client to attempt to urinate again may not be effective if the client is experiencing bladder distention or another underlying issue preventing urination.
Choice D rationale
Evaluating the client for bladder distention is the most appropriate action. Bladder distention can cause lower abdominal discomfort and difficulty urinating. Assessing for distention can help determine if the client needs further intervention, such as catheterization.

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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

The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation but reports pain when the pressure is released. Which action should the nurse implement?

Correct Answer is C

Explanation

An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample.After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

Correct Answer is D

Explanation

The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy. While interviewing the client, which assessment technique should the nurse use when asking about the client’s use of illegal drugs and alcohol?

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