Nokea
The nurse is talking with a client who has schizophrenia. The client states, 'I had a pet rabbit when I was growing up. Carrots are probably my favorite vegetable. Do you know that oranges grow on trees?' The nurse should recognize that the client is demonstrating
- A. associative looseness
- B. concrete thinking
- C. tangentiality
- D. neologisms
Correct Answer: C
Rationale: Tangentiality involves shifting topics without clear connections, as seen in the client’s unrelated statements about rabbits, carrots, and oranges. Associative looseness is more disorganized, concrete thinking lacks abstract thought, and neologisms involve invented words.
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The nurse is collecting data from an 18-month-old client. The nurse should suggest referral for a developmental screening test if the client
- A. does not notice when others are upset
- B. eats food using the fingers
- C. follows 1-step commands without gestures
- D. has a vocabulary of 5 words
Correct Answer: D
Rationale: An 18-month-old should have a vocabulary of 10-20 words. A vocabulary of only 5 words indicates a potential speech delay, warranting developmental screening. Noticing others' emotions develops later, finger-eating is normal, and following 1-step commands is age-appropriate.
The nurse is caring for a 70-year-old client with diabetic retinopathy. Which of the following statements by the client would be a priority to follow up?
- A. Half of my vision looks like it is being covered by a curtain
- B. I wear reading glasses when reading the newspaper
- C. My vision is cloudy with a glare around bright lights
- D. Colors appear less bright than when I was younger
Correct Answer: A
Rationale: A 'curtain' over half the vision suggests retinal detachment, a medical emergency requiring immediate intervention to prevent permanent vision loss. Reading glasses are normal, cloudy vision or glare may indicate cataracts, and less bright colors are age-related, but none are as urgent.
The nurse enters the room of an adult who is having a grand mal seizure. Which initial action is appropriate?
- A. Put a padded tongue blade in the client's mouth.
- B. Restrain the client.
- C. Turn the client's head to the side.
- D. Call the physician immediately.
Correct Answer: C
Rationale: Turning the head to the side during a seizure prevents airway obstruction by saliva or vomit, prioritizing safety, unlike tongue blades (risk injury), restraints, or immediate physician calls.
The practical nurse is caring for a client with newly diagnosed infective endocarditis. Which assessment finding by the nurse is the most concerning?
- A. Pain and pallor in one foot
- B. Pain in both knees
- C. Splinter hemorrhages in the nail beds
- D. Temperature of 38.2°C (100.8°F)
Correct Answer: A
Rationale: Pain and pallor in one foot suggest an embolic event, a serious complication of infective endocarditis that could lead to tissue ischemia or infarction, requiring urgent intervention. Knee pain, splinter hemorrhages, and mild fever are less immediately threatening.
A man is being discharged following a vasectomy. Which comment by the client indicates a need for more instruction?
- A. I will wear this scrotal support for the next few days.'
- B. I will continue to use a condom for the next two weeks.'
- C. My wife and I have decided that the four children we have are all we want.'
- D. I will keep the area clean and observe for signs of infection.'
Correct Answer: B
Rationale: Condom use is needed for 6-12 weeks post-vasectomy until azoospermia is confirmed, not just 2 weeks. Scrotal support, family planning, and hygiene are appropriate.