Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for an older adult client who has dementia.
Which of the following questions should the nurse ask to assess the client's abstract thinking?
A. "What is meant by the saying, 'Don't beat around the bush?".
Asking the client “What is meant by the saying, ‘Don’t beat around the bush?’” is a way to assess the client’s abstract thinking. Abstract thinking involves understanding concepts and ideas that are not concrete or tangible, such as interpreting figurative language or proverbs.
B. "Can you tell me the state where you were born?".
Choice B is incorrect because it assesses the client’s memory rather than their abstract thinking.
C. "Can you count backward from 100 in intervals of 7?".
Choice C is incorrect because it assesses the client’s attention and concentration rather than their abstract thinking.
D. "What do you understand about your condition?".
Choice D is incorrect because it assesses the client’s insight and understanding of their condition rather than their abstract thinking.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Adult Medical Surgical 2019 Proctored Exam. Take the full exam now
Full Explanation
Asking the client “What is meant by the saying, ‘Don’t beat around the bush?’” is a way to assess the client’s abstract thinking.
Abstract thinking involves understanding concepts and ideas that are not concrete or tangible, such as interpreting figurative language or proverbs.
Choice B is incorrect because it assesses the client’s memory rather than their abstract thinking.
Choice C is incorrect because it assesses the client’s attention and concentration rather than their abstract thinking.
Choice D is incorrect because it assesses the client’s insight and understanding of their condition rather than their abstract thinking.
Similar Questions
A nurse is monitoring an older adult client who has an exacerbation of chronic lymphocytic leukemia.
The nurse notes petechiae on the client's skin.
Which of the following actions should the nurse take?
A. Implement airborne precautions.
Choice A is incorrect because airborne precautions are used to prevent the spread of infectious diseases that are transmitted through the air, and are not necessary in this situation.
B. Determine the client's blood type.
Choice B is incorrect because determining the client’s blood type is not necessary in this situation.
C. Institute bleeding precautions.
The nurse should institute bleeding precautions for the client. Petechiae are small red or purple spots on the skin caused by broken capillaries, which can be a sign of low platelet count (thrombocytopenia) and an increased risk of bleeding. Bleeding precautions include measures such as using a soft-bristled toothbrush, avoiding injections, and avoiding activities that could result in injury.
D. Avoid administering IV pain medication.
Choice D is incorrect because avoiding IV pain medication is not necessary in this situation; however, the nurse should monitor the client for signs of bleeding and bruising.
Full Explanation
The nurse should institute bleeding precautions for the client.
Petechiae are small red or purple spots on the skin caused by broken capillaries, which can be a sign of low platelet count (thrombocytopenia) and an increased risk of bleeding.
Bleeding precautions include measures such as using a soft-bristled toothbrush, avoiding injections, and avoiding activities that could result in injury.
Choice A is incorrect because airborne precautions are used to prevent the spread of infectious diseases that are transmitted through the air, and are not necessary in this situation.
Choice B is incorrect because determining the client’s blood type is not necessary in this situation.
Choice D is incorrect because avoiding IV pain medication is not necessary in this situation; however, the nurse should monitor the client for signs of bleeding and bruising.
A nurse is preparing to perform ocular irrigation for a client following a chemical splash to the eye.
Which of the following actions should the nurse plan to take first?
A. Place a strip of pH paper onto the cul-de-sac of the affected eye.
Choice A is incorrect because airborne precautions are used to prevent the spread of infectious diseases that are transmitted through the air, and are not necessary in this situation.
B. Administer proparacaine eye drops into the affected eye.
Choice B is incorrect because administering proparacaine eye drops into the affected eye is not the first action the nurse should take. Proparacaine is a topical anesthetic that can be used to numb the eye before performing ocular irrigation, but it is not the first action the nurse should take.
C. Install 0.9% sodium chloride solution into the affected eye.
Choice C is incorrect because installing 0.9% sodium chloride solution into the affected eye is not the first action the nurse should take; the nurse should first collect information about the irritant that caused the injury before performing ocular irrigation.
D. Collect information about the irritant that caused the injury.
The first action the nurse should take is to collect information about the irritant that caused the injury. This information is important because it can help determine the appropriate treatment and irrigation solution to use.
Full Explanation
The first action the nurse should take is to collect information about the irritant that caused the injury.
This information is important because it can help determine the appropriate treatment and irrigation solution to use.
Choice A is incorrect because airborne precautions are used to prevent the spread of infectious diseases that are transmitted through the air, and are not necessary in this situation.
Choice B is incorrect because administering proparacaine eye drops into the affected eye is not the first action the nurse should take.
Proparacaine is a topical anesthetic that can be used to numb the eye before performing ocular irrigation, but it is not the first action the nurse should take.
Choice C is incorrect because installing 0.9% sodium chloride solution into the affected eye is not the first action the nurse should take; the nurse should first collect information about the irritant that caused the injury before performing ocular irrigation.
A nurse is caring for a client who has bladder cancer and a WBC count of 900/mm.
Which of the following actions should the nurse take?
A. Apply pressure to venipuncture sites for 10 min.
Choice A Applying pressure to venipuncture sites for 10 min is not necessary for a low WBC count.
B. Move the client to a negative pressure room.
Choice B Moving the client to a negative pressure room is not necessary for a low WBC count.
C. Instruct the client to avoid eating raw fruit.
Instruct the client to avoid eating raw fruit. A low white blood cell count can be caused by cancer or cancer treatment and can increase the risk of infection. One precaution that can be taken is to avoid all pre-cut fresh fruits and vegetables in delis, restaurants, and grocery stores.
D. Use contact isolation while providing care.
Choice D Contact isolation while providing care is not necessary for a low WBC count.
Full Explanation
Instruct the client to avoid eating raw fruit.
A low white blood cell count can be caused by cancer or cancer treatment and can increase the risk of infection.
One precaution that can be taken is to avoid all pre-cut fresh fruits and vegetables in delis, restaurants, and grocery stores.
Choice A Applying pressure to venipuncture sites for 10 min is not necessary for a low WBC count.
Choice B Moving the client to a negative pressure room is not necessary for a low WBC count.
Choice D Contact isolation while providing care is not necessary for a low WBC count.