When family members express their concern about their father’s recent memory loss, which assessment should the nurse suggest?

Ask the client if he knows the year he married his wife.

Determine if the client can recall what he ate for breakfast.

Instruct the client to follow a three-step task.

Tell the client to repeat a series of unrelated numbers.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Asking the client if he knows the year he married his wife assesses long-term memory, not recent memory.
Choice B rationale
Determining if the client can recall what he ate for breakfast assesses recent memory but does not provide a comprehensive assessment.
Choice C rationale
Instructing the client to follow a three-step task assesses the client’s ability to process and remember recent information, providing a more thorough evaluation of recent memory.
Choice D rationale
Telling the client to repeat a series of unrelated numbers assesses short-term memory and attention, not specifically recent memory.

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Correct Answer is C

Explanation

Choice A rationale
Asking the client to complete a common proverb or saying can provide some insight into cognitive function and language skills, but it may not comprehensively assess speech patterns. This method may also be influenced by the client’s familiarity with specific proverbs.
Choice B rationale
Having the client repeat a phrase containing alliteration can assess specific aspects of speech, such as articulation and fluency. However, it may not provide a holistic assessment of speech patterns and may not be suitable for all clients.
Choice C rationale
Noting the client’s responses during the initial interview allows the nurse to observe the client’s spontaneous speech patterns, including articulation, fluency, rate, and coherence, during the natural flow of conversation. This approach provides a comprehensive assessment of speech abilities in various contexts.
Choice D rationale
Listening while the client reads items listed on the menu can assess reading ability and pronunciation, but it may not fully capture speech patterns in spontaneous conversation or communication. Additionally, it may not be relevant to clients who may have difficulty reading or have limited literacy skills.

A. Detailed Questions about a symptom. B. Open-ended Questioning. C. Closed-ended Questions. D. Leading Questions.

Correct Answer is B

Explanation

Choice A rationale
Detailed questions about a symptom may be useful but can limit the client’s ability to provide a comprehensive description of the sputum.
Choice B rationale
Open-ended questioning allows the client to describe the sputum in their own words, providing more detailed and accurate information.
Choice C rationale
Closed-ended questions may limit the client’s responses and fail to capture important details about the sputum.
Choice D rationale
Leading questions can bias the client’s responses and may not provide accurate information about the sputum.

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When family members express their concern about their father’s recent memory loss, which assessment should the nurse suggest?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an admission assessment, which approach should the nurse use to assess a client’s speech patterns?

Correct Answer is C

Explanation

While completing a health assessment for a client being admitted with bilateral pneumonia, the nurse asks the client to describe the sputum. Which communication technique should the nurse use to obtain this information?

Correct Answer is B

Explanation

In assessing a client’s neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?

While interviewing a newly admitted older female client, the nurse observes that the client ignores Questions asked by the nurse, and speaks loudly to her son who brought her to the hospital. Which action should the nurse implement first?

After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high-pitched almost continuous gurgling in two quadrants. Which action should the nurse implement first?

The nurse observes that a client is experiencing melena.Which serum laboratory test should the nurse monitor in response to this finding?

While completing an admission assessment, the nurse is unable to palpate the client’s left dorsalis pedis (DP) pulse. Which intervention is most important for the nurse to implement?

A client who is admitted for an acute stroke reports the onset of a burning sensation in the hands and legs. Which action should the nurse implement to identify additional findings that are consistent with the client’s paresthesia?

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?

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?