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?

Normal mental status for age.

Impaired memory.

Impaired concentration.

Impaired thinking.

Answer and Explanation

The Correct Answer is D

A) Normal mental status for age: This response would suggest that the client's cognitive functions are appropriate for her age and educational background, which is not the case here. The response to the proverb "Glass Houses" indicates a lack of understanding or incorrect interpretation, which is not consistent with normal mental status.

B) Impaired memory: Impaired memory would typically manifest as difficulty recalling past events, recent information, or specific details. The client's response to the proverb does not indicate a memory problem but rather a difficulty in interpreting abstract concepts.

C) Impaired concentration: Impaired concentration would usually be indicated by the client's inability to focus on the conversation, becoming easily distracted, or having trouble maintaining attention. The client’s response to the proverb suggests more of a cognitive processing issue rather than an attention issue.

D) Impaired thinking: This is the most accurate conclusion. The client's response to the proverb "Glass Houses" ("It will break the windows") suggests difficulty with abstract thinking and interpreting common proverbs. Proverbs are often used to assess abstract thinking and reasoning abilities. A correct response would typically relate to the proverb's intended meaning about hypocrisy or not criticizing others when you have faults yourself, indicating that the client might have issues with abstract reasoning and impaired thinking.

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Correct Answer is B

Explanation

Answer: B. Place the dorsum of the hand on the client's forehead.

Rationale:

A) Ask the client to describe any other related symptoms.
While asking the client about symptoms related to fever, such as chills or sweating, can provide useful subjective information, it is not a reliable or objective method to confirm fever. Direct temperature measurement is needed for confirmation.

B) Place the dorsum of the hand on the client's forehead.
Placing the dorsum (back) of the hand on the client’s forehead is a common method to assess skin temperature. While this action provides a quick, non-invasive estimation of whether the client feels warm, it still requires confirmation with an actual temperature measurement using a thermometer for an objective assessment.

C) Use both hands to hold and palpate the client's hands.
Palpating the client's hands may provide information about extremity temperature or circulation, but it is not a reliable method for assessing core body temperature or confirming the presence of fever.

D) Lightly pinch a fold of skin over the client's sternum.
Pinching a fold of skin over the sternum assesses skin turgor, which is a measure of hydration and elasticity, not temperature. It does not provide any indication of whether the client has a fever.

A. Paresthesia. B. Rebound reaction to the needle points. C. Normal sensory finding. D. Marginal decline in sensory function.

Correct Answer is C

Explanation

A) Paresthesia: Paresthesia refers to abnormal sensations such as tingling, pricking, or numbness, typically without an external stimulus. The client's ability to discriminate two points at specific distances on the fingertips and palms does not indicate abnormal sensations or paresthesia.

B) Rebound reaction to the needle points: A rebound reaction would involve a delayed response or heightened sensitivity following the removal of a stimulus. This test does not measure rebound reactions but rather the ability to discriminate two separate points.

C) Normal sensory finding: The ability to sense two points at a distance of 3 mm on the fingertips and 10 mm on the palms is within the normal range for two-point discrimination. The fingertips typically have a higher density of sensory receptors and thus can discriminate smaller distances between two points, whereas the palms have fewer receptors and require a greater distance to discern two points.

D) Marginal decline in sensory function: The described ability to sense two points at these specific distances does not indicate a decline in sensory function. It aligns with normal findings for a middle-aged adult.

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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

To objectively confirm the presence of fever, before taking the client's temperature, which action should the nurse take?

Correct Answer is B

Explanation

Rationale:

Correct Answer is C

Explanation

When inspecting the client's skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client's history requires additional follow-up by the nurse?

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