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 A

Explanation

A) Initiate NPO status: The client's sudden cessation of breathing during deep palpation of the abdomen suggests peritoneal irritation, which could be indicative of a serious condition such as appendicitis or peritonitis. Initiating NPO (nothing by mouth) status is crucial in case emergency surgery is required to address the underlying abdominal pathology. NPO status helps prevent complications such as aspiration if surgery becomes necessary.

B) Restrict activity to bed rest: While bed rest may be indicated for certain abdominal conditions to reduce discomfort and prevent exacerbation of symptoms, it is not the most immediate priority in this scenario. The priority is addressing the potential need for emergency surgery and ensuring the client's safety.

C) Monitor urinary output: Monitoring urinary output is important for assessing hydration status and renal function, but it is not the most critical intervention in this scenario where peritoneal irritation is suspected.

D) Obtain an electrocardiogram: While an electrocardiogram (ECG) may be warranted in certain situations, such as if the client is experiencing chest pain or symptoms suggestive of cardiac involvement, it is not indicated as the most immediate action in this scenario of acute abdominal pain and potential peritoneal irritation.

A. Use a doppler ultrasonic stethoscope. B. Notify the healthcare provider. C. Apply warm blankets to both feet. D. Palpate pulse points with legs dependent.

Correct Answer is A

Explanation

When unable to palpate peripheral pulses, particularly the pedal pulses, using a Doppler ultrasonic stethoscope is an appropriate action to further assess circulation. The Doppler device uses sound waves to detect and amplify blood flow, allowing the nurse to locate pulses that may be difficult to palpate by traditional means. This assessment technique can provide valuable information about vascular status and potential circulation issues in the extremities.

B. Notify the healthcare provider:
Notifying the healthcare provider is not the initial action for the inability to palpate pedal pulses. The nurse should first attempt to assess the pulses using alternative methods, such as a Doppler device, before escalating the concern to the provider.

C. Apply warm blankets to both feet:
Applying warm blankets may be appropriate for clients with cold extremities due to peripheral vasoconstriction, but it does not directly address the issue of being unable to palpate pulses. Additionally, warmth alone may not improve circulation if there is an underlying vascular problem causing the absence of pulses.

D. Palpate pulse points with legs dependent:
Palpating pulse points with the legs dependent may facilitate blood flow to the lower extremities, potentially making pulses easier to palpate. However, if pulses are not palpable in the supine or seated position, it is unlikely that changing positions will significantly improve their detectability. Using a Doppler device would be a more appropriate next step in this situation.

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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

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