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 C

Explanation

A) Diabetes mellitus: While diabetes can lead to various complications affecting the nails, such as yellowing or thickening due to poor circulation and infections, it is not typically associated with brittle, concave (spoon-shaped) nails.

B) Recent candida infection: Candida infections can affect the nails, causing them to become discolored, thickened, or separated from the nail bed, but they do not typically cause the nails to become brittle and concave.

C) Iron deficiency anemia: This condition is often associated with brittle, spoon-shaped (concave) nails, known as koilonychia. Iron deficiency anemia affects the oxygen-carrying capacity of the blood, which can lead to changes in the nail beds, making them appear concave and brittle.

D) Coronary heart disease: While coronary heart disease can lead to changes in the nails due to poor circulation, it is not commonly associated with the specific finding of brittle, concave nails. Other nail changes might include clubbing or cyanosis, but not typically koilonychia.

A. Compare the shape of each of the pupils bilaterally with normal room light. B. Determine if dilation of the pupils occurs when the room is darkened. C. Note the speed of pupil constriction when a penlight is shined into the eye. D. Observe pupil size when focusing on a near object and then a far object.

Correct Answer is D

Explanation

A) Compare the shape of each of the pupils bilaterally with normal room light:
Assessing the shape of the pupils with normal room light is not specifically related to assessing pupillary reaction to accommodation. This action may be more relevant for assessing pupillary symmetry and shape, but it does not directly evaluate accommodation.

B) Determine if dilation of the pupils occurs when the room is darkened:
This action assesses the pupillary response to changes in light (pupillary light reflex), not specifically accommodation. While it is an important assessment, it does not target accommodation specifically.

C) Note the speed of pupil constriction when a penlight is shined into the eye:
This action assesses the pupillary light reflex, which involves the constriction of the pupils in response to light. While it is related to pupillary function, it does not specifically evaluate accommodation.

D) Observe pupil size when focusing on a near object and then a far object:
This action directly assesses the pupillary reaction to accommodation. When focusing on a near object, the pupils should constrict (miosis), and when focusing on a far object, the pupils should dilate (mydriasis). This response indicates that the pupils are adapting to changes in focal distance, demonstrating accommodation.

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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 observes the presence of brittle, concave curves to the nails of a client on assessment. Which information should the nurse obtain from the client that may explain the appearance of the nails?

Correct Answer is C

Explanation

To assess a client's pupillary reaction to accommodation, which action should the nurse take?

Correct Answer is D

Explanation

While auscultating a client's abdomen, the nurse hears a low-pitched blowing sound in the upper midline area. Which is the likely indication of this finding?

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