The nurse asks the client to explain the meaning of the phrase, "Every cloud has a silver lining." Which of the following is this part of the examination designed to measure?
a. Knowledge
b. Judgement
c. Association
d. Abstract thinking
D
Interpreting abstract ideas or concepts, such as in explaining the meaning of this phrase, reflects the capacity for abstract thinking. The client with altered mentation will likely interpret the phrase literally or merely rephrase the words.
An example of assessing knowledge would be asking the client the reason for seeking health care. The example of the phrase in the question is not designed to measure knowledge.
The nurse is not attempting to measure judgement in this example. An example of assessing judgement would be to ask the client what he or she would do if he or she suddenly became ill when alone at home.
The nurse is not attempting to measure association in this example. An example of assessing as-sociation would be to ask the client to complete a phrase such as, "A dog is to a beagle as a cat is to a _____."
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The clinical facility has a unit that has a focus of tertiary prevention. Which of the following goals is consistent with this focus?
A) Clients with pressure ulcers will have whirlpool therapy as indicated. B) Clients at risk for the development of pressure ulcers will be turned every 2 hours to prevent pressure ulcer development. C) Clients will be assessed for the presence of factors that place them at risk for pressure ulcer development. D) Clients will be taught to move in bed at least every 2 hours to prevent pressure ulcer development.
A patient is scheduled to have an electronystagmography as part of a diagnostic workup for Ménière's disease. What question is it most important for the nurse to ask the patient in preparation for this test?
A) "Have you ever experienced claustrophobia or feelings of anxiety while in enclosed spaces?" B) "Do you currently take sedatives, tranquilizers, or antihistamines on a regular basis?" C) "Do you have a history of falls or problems with loss of balance?" D) "Do you have a history of either high or low blood pressure?"
A nurse in an ophthalmology clinic instills an anticholinergic agent into a patient's eyes. The nurse provides teaching when the patient asks the reason for the drops. Which statement by the patient indicates a need for further teaching?
a. "The drops help prevent my lenses from moving during the exam." b. "The drops will cause me to have blurred vision and sensitivity to light." c. "These drops allow the ophthalmologist to see inside my eyes." d. "This medication anesthetizes my eyes so that the exam won't be painful."
A nurse could appropriately assess for the doll's eye reflex in a client who is a/an
a. conscious man who has been diagnosed with acute cerebrovascular accident. b. conscious young woman after an auto accident. c. unconscious elderly man who has sustained a cervical spine injury. d. unconscious teenager who has overdosed on drugs.